The American College of OB-Gyn has released a lengthy technical bulletin concerning Pap screening. It can be downloaded from here for anyone who is interested. I'm sure it supports their recently updated guidelines published last year.I haven't read it through yet.
Dr, I just read some posts by a Dr on another website. He says that women admitted to hospital in the States FOR ANYTHING have routine breast and pelvic exams.Is that right?If I had a toenail removed in the States, I'd be given a pelvic and breast exam??He has noticed some doctors omit or delegate to a nurse, this part of the exam for older and unattractive women and include it for attractive women.If that's true, no wonder you have issues with doctors doing unnecessary pelvic exams...sounds like they're obsessed with pelvic exams.That exam is so invasive and uncomfortable it is never done lightly in the UK, only when its absolutely necessary.My GP says its the most difficult exam for most women. I cannot believe it is done so often and routinely in the States.I guess many of your women just assume it will happen when they have a headache or sore ankle.Sorry, but its too creepy to get my head around.I wouldn't go near any of your doctors if a pelvic and breast exam were included for absolutely everything.Ellen
Ellen, there is no clear standard in the US for exams. Every state and hospital has its own format.But 30+ years ago, the gold standard was that every patient admitted to a hospital should have a complete physical, and for women that included a pelvic and Pap.That is not the custom anymore that I am aware of. It's not done at the hospitals I attend, but I can't answer for every hospital.
I worked in a hospital for over a year and I only know of one patient on my unit having one. She was admitted because of an ectopic pregnancy and they did one post-op. A lot of women I talked to never said anything about it. I was a CNA and most of my time was spent talking to patients and if routine pelvics were being done like that I would have heard. I was also a patient at the same hospital and admitted with abdominal pain and no one even suggested a pelvic exam (it was a digestive problem anyway). I can only speak of where I worked but, of course.
Well, at least its nice to hear that sort of thing doesn't happen everywhere.I'm Australian and have a medical phobia as a result of a bad childhood experience. Luckily I live in a country where most optional exams are easily avoided, although I've never seen a doctor for contraception, that might expose you to more excess or pressure.I don't have screening of any sort, not interested in looking for trouble and that's what it looks like to me. Over the years countless women have been worried sick over these tests and abnormal results, all over-detection issues and nothing to do with cancer. I can't see the point of it and don't think that awful anxiety is good for your health anyway.I had a breast reduction and used a great female surgeon. I felt comfortable with her and understood why she needed to check me for a year after the surgery. It was a great result and changed my life getting rid of that load.Our doctors don't do pelvic exams unless you have a medical problem in that area. I've been fortunate to never have a single issue in the pelvic region and hope to get through life never having had a pelvic exam. They sound dreadful and such difficult exposure. The vulnerability would scare me and I'd need a very sensitive female doctor. There is no way in the world I'd have one when I'm well. Total nonsense.My husband and I were virgins until the ripe old age of 25. Even if I were higher risk, I still wouldn't have smears, the risk from this cancer is too low to put your health in the hands of such an inaccurate test. That sort of life would be a misery for me, no life really.I hope this thread makes women realize most of these exams and tests are unnecessary, harmful or optional and as a result, have more control and peace in their lives.Thank you Dr for a great site.
"Ellen, there is no clear standard in the US for exams. Every state and hospital has its own format."This is disturbing because we never know what is really necessary and what is just a hospitals preference. What else is not necessary? Stripping and wearing gowns all the time? Total exposure for operations? A urinal when they are too lazy to disconnet ekg wires? Our body is really at their mercy just because that is the way they want do it?
Hi Dr,I read your article on informed consent a month ago and wanted to show you something that has made me very angry.I live in New Zealand and women are placed under extreme pressure to screen. I wanted more information and have been chased to the point of exhaustion. My husband even protected me from the district nurse who called at our home to speak to me about my "avoidance behaviour". It means there is one Dr I can see who respects my wish for more time.I was given a website reference by my doctor's surgery which I think is full of lies and is offensive in its patronizing tone.I believe doctors/surgeries/nurses who give out incorrect information to scare women are unprofessional.It worries me that women who are less aware will be influenced by this website.They say that 200 NZ women get cc every year and about 60 die from it. That sounds about right, its a small number.Now for this amazing statistic."Without screening 1 in 9 women develop cervical cancer and 1 out of 200 will die.With regular 3 yearly screening 1 out of 570 will develop cc and 1 out of 1280 will die".These are lies, total lies.Even very common lung cancer wouldn't affect 1 in 9 women. How can these publications get away with such dishonesty? Can they tell us any old rubbish?They say things like, "If you're an avoider" and "This kind of avoidance behaviour is not in your best interests".They then list the "excuses" provided by women and proceed to tear down the excuses.Why do we need an excuse?It's a cancer screening test for heaven's sake.I feel inclined to write to whatever watchdog keeps medical publications honest. I can't believe its lawful to lie like that. I know the disrespectful/arrogant/patronizing statements are accepted, but surely "statistics" are another matter.My husband says I'm wasting my time and they can say whatever they like and if women still stay away they'll say its 1 in 3 next time.Have we plunged to that low level?Gillianhttp://liveto100.everybody.co.nz/cx-screening-awareness
I agree Gillian. That website is a perfect example of what many here have complained about, completely exaggerated or made up statistics to scare women into screening.By all means lodge a complaint.On another topic, I note that India has halted use of the Gardasil vaccines because of too many deaths. I don't know what that's about, but I'll try to keep track of the story.
Gillian, Thanks for that link. That website just makes my blood boil. Oh and the comment that a pap smear tickles??!!! What planet are they on. And that it is not as intrusive as having a baby? Well I think it definitely is. Much more so.Nic
My 12 year old daughter told me today she doesn't want to get a pap smear.I was lost for words and said she doesn't need to worry about pap smears for a long time. When she's 25 she can decide whether she wants pap smears.She'd read online a 12 year old girl asking if she could get a pap smear. On another site it said all girls and women need pap smears, including virgins.This makes me angry that our babies are being frightened and worried about this test at their tender ages.I told her virgins don't need pap smears and it will be her decision whether she has then at 25. She asked if anyone could force you to have pap smears. I said, No....(although I now read American women have trouble getting the Pill unless they agree to them)When the time comes I plan to protect her from opportunistic smear-taking. I want it to be her decision and she should decide the interval to reduce the risk of a false positive. I won't pressure her either way. I had them until I had my hysterectomy at 38 and hated them. Had I had access to a site like this, I would have refused smears as my husband and I have had no other sexual partners. Not one doctor has ever told me that couples like us have little to fear from this cancer.That makes me mad and disappoints me, we should all have been given access to this information many years ago.Anyway she's gone off to her dancing class so I hope that's the end of that talk. She tells me her friends are all afraid of smears as well.The frenzy, fear and worry over this cancer and the test exhausts me. Give us all a break!Thank you Dr for a voice of common sense and reason and this fabulous and unique website.Rivahttp://www.drug3k.com/forum/Women-s-Health/Can-a-12-year-old-get-a-pap-smear-155036.htm
I was reading through a health site recently and couldn't believe the number of teenagers having cone biopsies, LEEP and other treatments for abnormal paps.I couldn't find the one I was reading but I've posted a similar one from another site, it's a couple of years old now but tells the awful business of a 19 year old girl being treated.We've all been told now that testing is unhelpful in young women. It makes me want to cry when I read this sort of thing, the damage is awful.I hope young women can find the strength to refuse this test now that the recommendations have been changed. If they're having some sort of procedure (this girl was having an abortion) they shouldn't be pap smeared just because the Dr has them in the right position. The consequences are severe.I couldn't bear going through that experience at my age, at 19 I'd have been in a padded room!What on earth are we doing to young women? (all women for that matter)TMcChttp://www.healthboards.com/boards/archive/index.php/t-485137.html
When I was in college one of my friends had a very similar story: Pregnant at 17, had an abortion, pap smear, very abnormal results, and LEEP. She honestly believed she would have gotten cancer and it's very unlikely she would not have. When she talked about it she'd cry; it's traumatic enough to go through an abortion at 17, but what happened with the pap made it a thousand times worse. And one nurse told her if she didn't sleep around none of this would have happened. People do make mistakes; no one is perfect.
It is pretty much 100% sure these girls have had unnecessary treatment. Teenagers DO produce really highly abnormal smears, but don't get cancer. I saw the damage that was being done in your country 8 years ago working as a nurse. It really upset me. I doubt there has ever been a case of cervical cancer in a 17 year old girl also, you'd probably find both parties were virgins and HPV infection is highly unlikely.You don't test teenagers and I have major doubt about the value of this testing in women under 25. It is of limited benefit to women over that age, but I've never believed it to be the most important thing by any means. To quit smoking would be much higher on the list. Of course, very high risk women have a better chance of benefiting from smears every 3 or 5 years from 25. I mean early starters, multiple partners, no condom use, history of STDs, smokers, poor diet/immune system. I know women who probably should have smears and don't and women who never miss and are too low risk to be bothering with this test.The countries that don't test women under 25 have put our health before politics, pressure group campaigning, profits, conservatism & paternalism.The Marie Stopes Group often push smears aggressively for any sexually active girl/woman no matter what age, but their information is incomplete. Screening is of no value in young women.I think they are well meaning but misguided.A friend had a conization at 20 and has been single ever since. She would never admit it but I think she avoids men because she believes she was punished for having sex outside of marriage. It was her first relationship and at 20 that hardly makes you an easy woman. Her doctor though said sleeping around has its consequences. She's lived like a nun ever since so I guess her doctor would approve. Although I doubt she sees a doctor anymore and I know she doesn't have smears anymore. That procedure was deeply scarring and I suspect will stop her having a full life.
I find it really telling that many medical websites still recommend annual pelvic exams for women. The gyn industry in the US would be crippled without routine exams. I also find it insulting that the ACOG changed the pap smear guidelines to protect babies. They don't care women suffer physically and mentally from these tests. It's all about potential life instead of actual life.That's all women are apparently: Baby makers and cash machines.
Anon, I don't understand that comment. I'm not aware that the the ACOG's change in guidelines had anything to do with babies.
I'm not sure but Anon might be talking about the comment that is sometimes made to back the need for these exams, that the profession must think of all women as pre-pregnant and protect reproductive capacity.Even women not planning kids can have an accidental pregnancy.It smacks of paternalism to me, like women need guardians.I've heard that reasoning used a few times to defend the need to get women in for check-ups to preserve their fertility/reproductive health.I think its hollow, money is behind these exams. A doctor in Brighton, England said if I wanted my health put at risk then have the exams, but I shouldn't think they were of any benefit in a well-woman. She also said no smears before you turn 25 AND only when you're sexually active (no testing at all for virgins) and never more often than every 3 years. She was shocked when I told her my doctor insisted I have my first as a 15 year old virgin. (along with the usual extras) I wouldn't agree to it now but at that time I had no idea about risk and was told by my doctor it was really important.I was at risk from cancer.I guess my doctor lied to me. I don't really have a doctor any more, just go to the student clinic when I'm unwell. I've given away the "annual physical", I don't think its a good idea for a healthy person to have those sorts of checks.Jemima
Did you all see the pap smear performed poolside on Kathy Griffin to promote womens' "health awareness"?It made me feel ill.I wish they would just stop!I'm drowning in health awareness.http://www.hollywoodbackwash.com/kathy-griffin-gets-public-pap-smear-on-camera/
I found some great information on the dangers of cervical screening during pregnancy. It's clear the huge over-treatment of women is contributing to an increase in premature deliveries.I also found a small piece by Dr Margaret McCartney, "Some women may not want cervical screening" published in the Jnl of Medical Screening and the response from the authors of an article that claimed women who don't vote are also less likely to have smears or some such nonsense.You'd think Dr McCartney was stating the obvious, but it's a statement that is rarely made by anyone let alone a Dr.Sadly, many of these great articles are only accessible if you subscribe to a medical journal and that can be quite expensive.It means the average woman rarely sees this material. At least this forum gives her a fighting chance.http://www.cancerhelp.org.uk/type/cervical-cancer/smears/pregnancy-and-abnormal-cervical-cellsWhy should preterm births be rising by Shennan and Bewley 332(7547):924-BMJDr McCartney's letter to the Editor of the Jnl of Medical Screening appears at Vol 17, No 1, 2010 at page 52 and the response by Dr Waller and Others.If you have trouble accessing this piece, google Dr McCartney and "Some women may not want cervical screening". If you can't find it, read the following which covers most of her response anyway.Not many doctors will come out and say not all women want screening and that's fine and all women should be told the absolute truth about screening, but I think their numbers are rising.http://blogs.ft.com/healthblog/2010/01/11/suffragettes-and-screening/#more-4841
I am glad I found this site. My friend called me the other day telling me how she hadn't had a pap smear in a few years and she was beside herself with worry. I told her how rare it is and I said to her do you know anybody who has had cervical cancer. Between us we couldn't think of a single person.Nic
I don't follow why there is so much pressure to have screening.In Scotland my aunt got a letter asking if a nurse could call on her, she said no and gets a new letter every few years and she says no again.Is anything else in medicine handled like this?I've never heard of anything like this sort of pressure.What is behind this? Is it these targets that some of you are talking about? I don't know whether they apply in Scotland.Here is something about these home visits. But my aunt still says NO! I fear if another person mentions pap smears to hear she might run them off her property!http://jpubhealth.oxfordjournals.org/cgi/reprint/18/1/94.pdfMoira
I have added to my links Elizabeth's reference on screening during pregnancy.
Cervical cancer is officially categorized as a "rare" cancer. Looking at pre-screening numbers and the definition of rare cancers, it would still have made the rare cancer category. The HUGE drop since screening in number terms is actually quite small.When you hear there has been a 70% drop in the death rate it sounds vast, but the numbers are small.http://www.wrongdiagnosis.com/c/cervical_cancer/prevalence.htm
Here's a follow up on the story that India has stopped giving cervical cancer vaccines because of deaths. Here are the deaths:“Four deaths in the target of 14,019 in Andhra and two in the target of 10,686 in Gujarat have been reported from among the children who were administered these vaccines. The cause of deaths was determined as viral fever, drowning, suicide, severe anaemia with malaria and suspected snake bite. Based on the concerns on these deaths, states have been advised not to carry out any further vaccinations at present,” Gandhiselvan said.These 6 deaths among 25000 from such disparate causes could hardly have been related to the vaccine. Can't imagine why India stopped the program, probably politics.
Dr. Sherman, I was reading the article from the ACOG that you posted. In the first paragraph they say in the 1970s CC affected 14.8 out of 100,000 women and in 2006 it affected 6.5 per 100,000 women.If that's true it means 0.0148% of women got CC in the 70s and 0.0065% in 2006. Those numbers are so tiny it sickens me. And except for a few differences the recommendations are to basically treat all women the same when it come to testing. There's no mention of informed consent and it hardly address the risks associated with false positives. It's a disgusting article which doesn't address any of the dangers of screening. And did it even occur to the people who wrote this that cancer screening is optional and some women may not want to screen?I know that for a very few women this screening has helped, but for the vast majority of us it hasn't helped, or worse, done more harm. It is very sad to see the medical community have this view of all women must test for CC. I'm from the US and the only time I was told I didn't have to screen was followed by a, " but I knew a 21 year old who died of CC in six months."No matter how many articles come out they will never be able to teach honesty and respect towards women.
Anon, statistics are treacherous. I agree with most of what you say, but remember that any woman should be concerned with her lifetime risk of getting cervical cancer, not her risk in any given year which is indeed tiny. The lifetime risk is still under 1%, small, but not minuscule.
Dr Sherman, Can you be more specific with what you said of the lifetime risk being than less than 1%? That could anything from .9% to .00001%. We're talking about a huge margin. Since I've been reading about this here I've brought it up with my friends. I think we all are unanamous in loathing this exam. One of my friends is Greek and her mother is a very modest Greek woman who married as a virgin and was widowed at 42. She has not so much as looked at another man since becoming a widow (has dressed completely in black)and yet she has been forced to have these humiliating exams like the rest of us. This is especially traumatic for her. Once again I say how could the medical profession be so insensitive to women's modesty. Also my question is that if you have been in a monogamous relationship for years or widowed for years isn't there a point where they could safely say that you won't be getting cc?Nic
I have had an interesting conversation with multiple women friends along these lines:- Me to them: Gosh, there is a lot of press about the flu, have you had a flu shot?- Their answer: No, I just don't believe that I am very likely to get the flu, so why bother.So I then explain how they are certainly much more likely to get the flu than to get Cervical cancer, yet they are quick to not only hop on the table once a year themselves ... but to try to bully me and other 'non-compliants' into getting PAPs.Well, I have to say that they try hard to quickly change the subject when confronted with actual data. In some ways I feel sorry for them, since they are really just trying to avoid acknowledging that they have really been abused by the medical field for so many years. If they admit that this data is true, then they admit that they have been unwittingly mistreated ... and that they have perpetuated that mistreatment onto other women.Especially those who have indoctrinated their own daughters into this cycle of abuse.
Nic, you can find various figures for the lifetime risk of cervical cancer. I found one reference for the US giving the lifetime risk as 1 in 116, or just under 0.9%. Found a mention for Australia of just over 1%. So you can take near 1% as a reasonable estimate.I don't know how definitive these studies were or what they are based on. I assume that the figures are for all women, both high and low relative risk.I think any woman in a long term mutually monogamous relationship with several negative Paps is at very low risk for cervical cancer. No doctor will advise never getting another Pap smear (unless you're over 65), but it is a reasonable personal decision for women who dislike the test. There are many other diseases that we're of much higher risk for.
I have been reading the autobiography of Jan Murray, the wife of an Australian politician. She tells of her tragic experience of having a pap smear at her 6 week post natal check up that came back with an abnormal reading.. She was advised not to have any more children. However, she became pregnant and her doctor told her she needed to have an immediate hysterectomy or she would die. Of course the baby would die as well. After the hysterectomy, the doctor informed her that it was not an invasive cancer after all. His reply to the unnecessary hysterectomy: "what do want your uterus for. All they do is bleed and cause headaches."Nic
I just want to add to the above post that if situations like that were common then (mid 1960's ) the supposed numbers of lives saved are skewered. That was one life saved for one life lost. Net lives saved =0. Now take into account that the hysterectomy was unnecessary, we have a negative 1 life saved.Nic
It's all in the promotion and sales pitch.I think if doctors told women there was a 99% chance they WOULDN'T get cancer...and even with smears there remained a 0.35% risk of getting cervical cancer...BUT screening sent somewhere between 30% and up to 95% for "treatment" and biopsies...and that at least 95% of that treatment is absolutely unnecessary and leaves a percentage of women with health problems....how many women would have smears?My personal risk of this cancer is too low to calculate...my partner and I have had no other sexual partners. Thank goodness I was alerted to the real "value" of smears before the pressure started and have always refused, sometimes with great difficulty. My doctor has given up...I'm now 46.My friend works in medical research and was surprised to find out the real facts about this cancer and testing and didn't agree with the "story" being told to women and the pressure and coercive tactics...he circulated the real story around college. (a lot of years ago now)I'm grateful beyond words. I've known many poor women who've had biopsies over the years and a friend fainted and vomited during the LEEP procedure, she was so distressed and humiliated. The indignity is really awful and many of these things were done back in the days when almost all gyn's in Australia were male. I felt terribly sorry for them. A few still test out of fear, others have given they away, but only tell me...fearing a backlash from the pap smear fan club. One younger friend was refused the Pill when she didn't want screening. I helped her lodge a complaint and she got her script with no test. I was surprised doctors in American and Canada do that and get away with it AND the pelvic exam in stirrups stuff is too horrifying for words!I cannot begin to convey how lucky I feel not to have been forced into this testing nightmare.I think this testing has stopped the bulk of women from leading a private and dignified life. To test all women annually or even 2 or 3 yearly when the risk is so low is bad enough, but to conceal risk, lie to them about the risk of this cancer and pressure them like mad is inhuman. Treating women like slabs of meat deserving of zero dignity and no right to make an educated decision about screening. What gives doctors the right to treat women in this way?This testing has shaken my trust in the profession and respect for doctors is a thing of the past.(All of those statistics by the way came from this site or Violet to Blue - two amazing sites!!!!)Karina
Here's an interesting link to a booklet on legal issues surrounding pap smears in NSW Australia.http://www.csp.nsw.gov.au/assets/downloads/legal_doc.pdfNic
"I think any woman in a long term mutually monogamous relationship with several negative Paps is at very low risk for cervical cancer." Dr, I first read a comment like this in your article about informed consent. I was floored. In my past I had a crazy period and made "a few mistakes." I have been with my fiancee for 3 1/2 years and I've had several negative paps and a negative HPV test in May 2008 (I was 24 and they did it *without* my consent). I didn't know they tested me for HPV and other STDs, but regardless they all came out negative. (I think they just wanted to charge me more because I worked for the hospital they are affiliated with and I had a ton of discounts).In March 2009 I went back to my doctor for a mystery allergy and the whole pap thing came up again. With all these negative tests I started to question if I really needed this done every year or at all. With no resources to back me up at the time I refused just because I didn't like it.In the past I thought maybe my risk was pretty high, but now I don't think it is any more than the average women. I guess I'm somewhat happy with the HPV test being negative because at least I know I don't have HPV. Your article and this blog are a wonderful resource and that one statement made me feel so much better. When my doctor's office called to "remind me that I missed my pap" last year I had facts to back me up. I think having knowledge is real empowerment. Thank you!
I've said repetitively that I'm not an expert on these issues and I don't want to give anyone false assurances.There are several questions I have about the need for Pap smears in the setting of women wanting to stop them:Does infection with a dangerous strain of HPV always lead to early and persistent changes on smear in a susceptible woman? If not, how long does it take for changes to appear or reappear? In other words, after possible infection, how long does it take to consider yourself safe if multiple subsequent Paps become negative? It takes 5 to 20 years for cervical cancer to develop with 8-15 being average so potentially you could be at risk for a long time after an abnormal Pap. If an HPV test is also negative, you should be very safe if you have no further exposure.The answers to my questions may or may not be fully known. If any of you have answers please post them.
The question that confuses me: We both had two partners before getting together and it was safe sex all the time.We still use condoms because we don't have a HOPE program near our home and I refuse to submit while they do all sorts of unnecessary and unrelated things to my body to get BC.A doctor who was angry I wasn't just obeying orders like most other women told me that the virus may have been living on the scrotum of one of my past partners or current partner and infected me. That meant I would be "at risk" from cancer for the rest of my life and needed yearly smears.He didn't say how high that risk was..if it's less than 1%, I couldn't care less, especially if the risk of a conization or LEEP is very high over my life.I still think the wide net doctors cast over all of us is just to scare us into testing, even low risk women.I know in the Netherlands women are sometimes offered self administered kits from around 30 and every 5 years, not yearly. My pen pal lives in that country. I still would be unhappy to use one of those because the test is far from perfect and once you get an abnormal result, they've got you!You're then up for the works usually in a hospital setting and then they demand 3 or 6 monthly testing.(even after a false positive)I just will not get drawn into that and then find I've got a damaged cervix and have turned into a patient even though I was always healthy.It is comforting to find some balance and honesty.I think because you are not an expert in this area Dr, it probably has enabled you to look at these things with an open mind. I don't think the experts can do that. My 59 year old auntie is a virgin, she has never even had a boyfriend. Yet she has been pap smeared every year since she was 16. She hates it more than words can say, but the doctor has terrified her. The way this test is over-used is very bad. I can't understand why the medical societies continue to allow this to happen. I know one of those groups still include virgins in everything they recommend, it's a powerful indication to me that they regard women as money-making commodities and not adults in charge of their own healthcare.Are men ever regarded in this way? I can't think of any examples - my father told the Dr he'd worry about cancer when he actually had cancer and not before, so...back off. That was happily accepted and nothing more has been said, yet my poor Auntie is never left alone. She is a very reserved woman, so its not a fair match and it takes a lot out of her...maybe she should find another doctor, but the fear is so great, it wouldn't be easy after so many years of dishonest scare-mongering.Sophia
As I understand it American doctors consider women liars if they claim to be virgins past a certain age. I heard one doctor say on one forum, "you can't trust women to tell you the truth".That indicated to me that doctors feel they can judge women and make decisions for them...so their medical society recommends testing and exams for all women at 21, even virgins. (most doctors start testing when you're in your teens)They see themselves as our parents or worse than that, our domineering guardians.They don't seem to hear what they are actually saying and how rude it is to women.No woman needs or must have any preventative medicine. It's entirely voluntary.That is accepted for men, but not for women.I have never accepted that sort of thinking and have changed my doctor about a dozen times over the last 20 years. I tend to stay away from doctors...that gives you the best chance of staying healthy.I don't worry about cancer, yet women who agree to all this testing and the exams are constantly worried about cancer and never stop talking about it. It is very unhealthy.I'll worry about cancer if I actually get it and not before...Sherry
http://www.annals.org/content/118/11/901.full.pdfThis article says we should not screen for ovarian cancer for various reasons, but seems to suggest the most important reason is the low incidence of this cancer.Yet ovarian cancer occurs more often than cervical cancer.Why do they think all these false positives and harmful work-up is warranted for a cancer less common than ovarian cancer? Why is cervical cancer screening the exception to all the screening rules? Things like low incidence of the cancer, unreliable test and over-investigation.CC and the pap test has all those things.Just wondered...
I was reading another forum and a NZ man was complaining that a notice appears at the local surgery saying if women ignore three calls for a smear, the district nurse will pay her a visit.I was shocked to read that...why would you bother with a cancer that doesn't occur all that often?If you want to save lives, why not pay a visit to men who decline prostate screening? It's a far more common cancer or smokers...many things occur more often than cervical cancer.I feel it's the target payments and performance bonuses that are behind this pressure.Also, isn't it telling that the govt pays incentives to screen for the cancer that occurs the least? That tells me this screening is a long shot and that's why coverage is everything.DLB
I was recently reading a miscarriage forum and was shocked at how many women had previously had cervical procedures, like leep or conization, then I found this article: http://women.webmd.com/news/20040504/cervix-treatment-may-endanger-pregnancy-laterThe thing is, these women were very young, under 25. They are understandably grieving about sometimes multiple miscarriages. It seems incredibly sad to think that their previous cervical procedures (which perhaps caused their miscarriages) may not have been necessary.
I can't read those forums. I personally know of four young girls who've had negative cone biopsies. LEEP and cone biopsies are the biopsies that are most likely to leave you with problems.For years doctors have flipped off concerns about these huge numbers of "minor" procedures. Like so many things about this testing, they were very wrong and poor women have suffered as a result.I read somewhere that having a damaged cervix is part of being a responsible woman these days.Sadly, very true.
I am DESESPERATE!!! There´s have been no talk about this in this blog, but I´m a female who is required to unergo an EKG for plastic surgery (minor, eyelid). I flatly don´t want the procedure done, and I cannot be accommodated, although that might be arranged. I would die of cardiac arrest rather than having it done by mostly male techs which are not even required to have a bachelor´s degree!!! They only have a couple of day´s training, seriously, and they do touch you??? Am I legally required to have it done??? Can I refuse, or will I have to forego the offer, for I had been offered a real and sustantial discount... I wounder, what do other women THINK??? What's worse, I must admit my ignorance, what does the procedure involve for females, modesty-wise???? CAN SOMEBODY ANSWER??? Thank you.
Maria,Probably well over 90% of ECG techs are women. If you ask for a female tech, nearly every place will accommodate you. The exact procedure varies from place to place. You may or may not be asked to take off your bra (though the test can be inaccurate if a bra is left on), but if so you will be given a gown.Most ECG techs have minimal training, male or female. That's true everywhere in medicine.Can't tell you if you can refuse an ECG. Depends how minor the procedure actually will be. They may cancel the procedure if you do. It may well be covered under state or federal regulations.
Maria,http://en.allexperts.com/q/Heart-Cardiology-964/ECG-7.htmThe above link is a good explanation about how to get your modesty accommodated. Remember that YOU are in-charge, not the tech. So if they refuse to accommodate, complain and/or go elsewhere.It seems that it is always about what is easiest and fastest for the doctor/nurse/technician and NOT about what is least intrusive or stressful for the patient.Another option I would personally consider, if such minimal training is required for these techs ... why can't you learn how & place the pads yourself? There's a video on YouTube ... though I notice that they never show it being done on a woman.Realize just don't want to take the extra few minutes to keep the woman covered, they don't care about you or your feelings .. they just want to get 'the job' done as quickly as possible.Doesn't that make you feel all warm and fuzzy?
This article was mentioned above:JAMA. 2004;291(17):2100-2106called Treatment for Cervical Intraepithelial Neoplasia and Risk of Preterm Delivery. It studied the risk of premature rupture of the membranes leading to premature delivery in women with abnormal Pap smears either treated with LEEP or similar therapy or untreated who subsequently became pregnant.The results, the incidence of premature rupture was more than doubled in women who had had cone procedures, 3.5% vs. 8%. There is little doubt that conal procedures should be avoided in young women who may still become pregnant.
I should add to the above that cone procedures should be avoided whenever possible. Obviously cancer is worse, but likely most of these procedures can be avoided.Here's a report of a study showing that the HPV DNA test is more accurate than Pap smears, though neither is perfect. The full article should become available on BMJ online soon for April 27th.
I had an EKG last month.I asked for a female tech and was asked to remove my bra, no gown...once she'd placed the leads she put a small towel over my breasts.Even women are fairly casual, the door opened and closed a couple of times which made me uncomfortable - it was other female techs coming in to talk to my tech, but I still thought it was unprofessional.In the end I asked her for some privacy for the rest of the test and she didn't hesitate to lock the door.Speak up, make clear your request for a female tech and tell them if they fall short is my advice.I also requested a female...sorry I have no idea how to spell "anaethesiologist" when I had some minor surgery because I heard your gown is pulled down while they fix leads and they can be casual about it.My female surgeon got a female doctor to put me to sleep.I haven't had a single problem but always make my request firm, clear and polite and I'd leave if they couldn't help me.I've had no issues with male doctors but was assualted as a teenager so have trust issues with men.Leila
Dr Sherman I wonder if all these biopses and and leeps don't also contribute higher cervical cancer risks in the future? As I see it, damaging tissue must lead to the cervix being more vulnerable to infection by the virus. Any thoughts?Nic
I've wondered about that too...I've heard regular irritation can cause lung, rectal, skin and esophageal cancer and I guess many other cancers.When you think some poor women have 3 and 6 monthly smears after an abnormal smear and the average is still one a year in the States - some women bleed after smears and after treatment you can have a discharge and be sore for months.The harm caused by this testing has been hidden, but I think the harm and worry caused to huge numbers of well women can never be justified when the cancer would affect 1% of women with no screening.Instead in the States about 95% of women have biopsies.Are we all stupid not to have looked harder at this test? It is hard to get to the truth, this site has made a vast difference and we do face huge pressure from every quarter = doctors, media, friends.We can't be blamed...but now we know, it can only be our fault to keep this happening. (unless women have given express informed consent)I did my bit recently and totally refused the exam when I needed more Pills. I was determined and the Dr asked me why I suddenly felt this way. I explained and I got my prescription.I have been laughed at and scolded over the years when I had queries, but for the first time I felt empowered, I have the answers I need and they will protect me.I read recently that this testing is a risky form of catastrophe insurance...I agree with that statement. I don't worry about catastrophes in my life and I'm not prepared to risk my health to cover such a small risk.Georgia P
Bravo to you Georgia for standing firm and taking charge of your heath and healthcare!How would you suggest we address this topic with our healthcare providers when they bring it up? I am talking about the ambush type of situations when one goes to see the Dr. for an entirely different matter and is confronted with the dreaded pap/pelvic demands and the ensuing pressure and scare tactics to comply. I would like to find a Dr. who is respectful of my wishes in that regard and doesn't push the issue. I don't have the time or the unlimited resources to make appointment after appointment with every Dr. in town until I find one who is willing to work with me and allow me to make my own choices.I feel as though I must have a script ready to deal with whatever the Dr. throws at me. It shouldn't be like that. A Dr's office shoul be a place where one goes for help, not a place for bullying and the withholding of information that prevents informed consent.
I agree with the last poster.Dr's bank on our ignorance.If we have facts, it's harder to scare us or punish us with words.Must be a lot of worried doctors wondering where all these women are getting to the facts, rather than accepting the nonsense pushed at us on light weight websites and womens' mags.
Nic and others have asked, could multiple Paps and procedures lead to a greater incidence of cervical cancer? Sounds like it could be plausible but there is no information available. It's certainly not a recognized factor. It's not comparable for example to asking how many breast cancers are due to cumulative radiation from repeated mammograms.Those of you who would refuse smears would indeed be helped by having ready a list, written or oral, of your reasons why. That could include some of the points given in my article. If you're American, the new ACOG guidelines may help you as many doctors want to do more Paps than the guidelines now recommend. The biggest medical points would include a history of prior negative Paps while being in a long term mutually monogamous relationship or being sexually inactive.I'm sure someone can post a sample point sheet for refusing further tests.
Dr, just on virgins.My doctor told me that they include virgins because many girls are victims of incest or childhood sexual assault and are unwilling or unable to disclose these facts.I was a bit surprised that justified putting the rights and health of those girls ahead of us.I'm a virgin and don't fall into one of those groups.Also, I've been asked whether I'm actually a virgin. If you've had any sexual activity, then you're not a virgin. I am...One doctor asked me why I was a virgin at 28...was I being too fussy. I made a complaint with the female doctor I usually see at that clinic. I only agreed to see him because I'd sprained my big toe. Yet the whole consult he went on and on about pap tests and my sex life or lack thereof.It does annoy me, the obsession with this test. It gives doctors the right to ask all sorts of personal questions and to ambush us with this test. I know a few women who ended up having pap tests when they went to the Dr with the flu or an upset stomach.One friend got a pap test because she had an infected eye...she wasn't sure how it happened, but the doctor was quite aggressive about it and just demanded she have one. She was cross that she let it happen, but felt powerless in that setting.Also, my doctor including virgins in case they're victims of sexual assault sounded to me like doctors have taken on a sort of parenting role. Not really appropriate with adult women.Donna
Donna,It is amazing how paternalistic doctors can get on the topic of Pap smears (and I don't mean to imply that only men do it as many women physicians have the same attitude). Yes, if you're a virgin there's always a small chance you could have cervical cancer, but that's a small chance on top of it being rare to begin with. We're talking less than 1 in a million here. It's abusive to pressure women into tests based on that, especially without giving them informed consent, explaining that their chance of needing further procedures that will prove to be negative are hundreds of times more likely than their chances of having cancer.
Donna, If your friends are premenopausal then remind them always to be "on your period" when they visit the doctor.Nic
I found you!I saw your article referenced on another forum and found a website for a urologist by the same name working on Staten Island. Took me a while to work out I had the wrong Dr Joel Sherman. (lots of privacy concerns in that field!)I've now read the whole article and wanted to thank you.I've been waiting for that article for about 10 years. The command to have smears starts fairly early and is something most women dread, choice and free will are never included, just the order to have smears and gyn checks every year from 18, and some doctors say 15 or 16.I've played dodge and weave and have made it to 28.I resent the threat that hangs over me every time I apply for a job or see a doctor. It will be a lifelong fight and I do resent that. I try not to get too angry with doctors but it has created a wedge between me and my doctor. She has called me silly, immature..."time to grow up".Nowhere is it accepted that women should have a choice about these things.We should be free to get medical care without having to explain ourselves all the time.It also feels like the list gets longer every year. My doctor now wants me to agree to an internal ultrasound every year if I won't agree to paps and a pelvic. No, I don't have any pelvic pain, no problems with my periods and don't want anyone poking around in my normal body. I don't agree to cardiologists poking around my chest either...what is this obsession with our female parts?You can imagine my reaction when I saw your article.Finally!!!!I really, really hope its the start of change and screening and routine checks will become extra things that you may or may not want.Dr, are you planning any more articles or a speaking tour?Or, interviews with the media?Chrissy
Well I'm glad you liked the article Chrissy. I have no plans for anything further. And no one is clamoring for interviews or speaking tours. I’ll let you know when the NY Times calls.In general, both the medical establishment and women's groups are opposed to the point of view on this website and neither of them is calling either.As a cardiologist though, I must tell you that I don't go poking around in any ones chest, neither women nor men. Don't do breast exams unless a woman asks, which is rare.
Dr, how can those groups be opposed to informed consent for women and cancer screening/preventative medicine?I've seen many articles on the risks of prostate screening and I doubt any man would be pressured or driven out of town with raised pitchforks if he refused testing, how can things be so terribly different and no one sees the hypocrisy?Even women's groups seem afraid to say anything bad about screening and the pressure women face.Gillian
Here's an article based on a published research paper that states if negative cervical screening is obtained with an HPV test, it is safe for a woman to go 5 years before the next test. That should be a boon.Gillian, the medical establishment and national women’s groups both have a vested interest in women's health. The test was very successful when it was devised 60 years ago long before informed consent was considered. Neither group is motivated to change their approach now that the evidence is different and we more clearly recognize the downside of screening.
Have any women here had a problem with their doctor after the recent changes to pap guidelines?My doctor still wants me to have a gyn exam every year. I doubt these things are helpful and only put up with them because I thought I needed a pap smear.I'm confused about that now, but apparently now I can go 3 years between paps. When I said that I probably would just have a pap every 3 years, my Dr became quite annoyed and said women would suffer taking that slack attitude.Is that really fair? If we're healthy, do we really need these breast and pelvic exams?I've found this forum very helpful. I hate paps and would prefer not to have them if the risk is 1% or even 2%, but my husband was very sexually active and used prostitutes when he was in the military and even though we've always used condoms, I guess my risk from this cancer is higher. I was a virgin when we met a year after he left the military.If we can limit the intrusions on the healthy female body then that is a great thing.
Anon, I have just posted the ACOG pamphlet on new guidelines for Pap smears in the women's links section. This pamphlet should be in every doctor's office that does Paps. But you can print it and bring it with you. It quite clearly states that you can go 2 years after a negative Pap and 3 if you've had 3 negative Paps. This is not controversial. I would show this pamphlet (which you can probably order) to any doctor who insists that yearly is best.I cannot answer the question of when is any individual's risk so small that you can stop Paps altogether (except for women >65 and those who've had a hysterectomy). A decision to stop Paps can be argued. At this point that is still a personal decision but there is a consensus that routine annual Paps are not needed.
Anon, if I were in your situation I'd probably follow Finland's guidelines of once every 5 years from age 30 to 65 years old. Even then the risks of a false positive are about 50%. Also, if you are at least 30 you might consider getting tested for HPV. I don't know too much about the test, but maybe it could help? In any case, do TONS of research and make your own decision. Don't let doctors with ulterior motives to influence you.
Dr. Sherman, It´s María again, I need to ask whether the 12 lead EKG is done as a routine procedure... Do they only do it if you have symptoms??? Do you have to be in the brink of cardiac arrest for them to do it??? Or, (what I dread) will they try to push it on you??? Is it that different, modesty wise, from the 3 lead EKG??? I forgot one of the most important things, is there any way I can ensure my husband is with me during the procedure? With him by my side, they usually realize we mean business!!! Still, if a male tech really has to do te 12 thing, I think I?m canceling the whole thing.
Maria, practices vary. A 12 lead ECG is standard if you're going to have general anesthesia. Maybe they'd forgo it if you're quite young with no history of heart disease. If you're going to have conscious sedation or local anesthesia it may be optional depending on local custom.Can't tell you whether they'll let your husband be there. Depends on what's being done and where it's being done. Ask your doctor ahead of time.Once again tho it's very unlikely that they can't accommodate a request for a female technician if you ask ahead of time.
This book was referenced above. I have obtained it and read the chapter on cervical cancer screening:Common Screening Tests, David M Eddy MD PhD Editor, American College of Physicians, 1991.Although this book is old by medical standards, Pap smears haven't changed much over the years. This chapter does support the efficacy of Pap screening in reducing the incidence of cervical cancer quoting many studies, the statistics of which aren't easy to follow. But the chapter's conclusions are simple. Women should be screened at least every 3 years beginning in their 20's and continuing to their 60's. For most women, a 3 year screening interval is appropriate.I find it astounding that this information was statistically evident 20 years ago and it has taken that long for American medicine to formally accept them. For 20 more years American medicine has been pushing annual Pap smears starting in the teens. I'm cynical enough to believe that if the recommendation had been for increased screening (and doctors' fees), they would have been accepted immediately.
This information has been around for more than 20 years. They've had research from Finland who have led the way in responsible and ethical screening. They also lead the world with prevention programs for diabetes, which is sweeping the world with our modern lifestyles.Australia is still testing teenagers and every 2 years until 70 years of age. The official start age is 20 for sexually active women, but because women receive no honest and complete risk information, many teenagers are tested at the doctors recommendation or even insistence or the teenagers ask for it after reading a women's magazine or watching one of the Papscreen ads.They say a review is happening here, but I suspect there are powerful over-screening groups here that will attempt to put their interests ahead of women's health care.A 21 year old girl with cervical cancer (who had a recent normal pap smear) has been interviewed a few times on morning television (to raise awareness) and this has prompted a surge in young girls asking for the test. They only get one side of the story. No one mentions the smear didn't help her or that this is a tragic and very rare case. Nor do they hear that screening carries high risks for very young women.My GP shares my concerns and can't believe the guidelines haven't changed after the States recently downgraded their guidelines. She feels compromised and is thinking of pulling out of the program and referring these women to a nearby clinic. She KNOWS she is risking the health of these young women for zero benefit. She has never participated in the financial incentives target program. Australia and Germany must now lead the way in useless testing and harmful excess. Yet they have the audacity to claim this program is the most successful in the world because we have the lowest mortality rate (Finland has fewer cases though) - they all conveniently forget the awful downside to this testing and the damage being done particularly to young women. If a young woman sued Papscreen, that might move things along, but at the moment women simply don't have enough information to connect the dots. Most women still feel grateful after a negative cone biopsy.Jane
I'm in Australia too and I have had one or two abnormal paps. What angers me is that nobody ever explained what that meant and of course I presumed that it was some kind of early stage cancer. At least I was never sent for a biopsy but I couldn't understand why they were doing nothing about it. How unprofessional of the doctors and health care workers not to explain what a abnormal reading meant. They just said come back in a year. What angers me is that a lot of doctors don't like patients using google but it's the only place patients can get the facts. I have learnt more in the last few weeks about paps on this blog than in the last twenty years of having them in clinics. In fact when I think of it, I have never been given ANY information at all on cervical cancer or pap smears. And I, like all my friends just thought it was something we had to do. When I think about it, I can't believe I did it just because I was told to.It's scary to think that we just did what we were told without question. It's like we're in a cult or something.Nic
Nic, I was always told by my father to doubt everything, always look further. When paps were first raised when I was about 22, I asked for evidence. The Dr basically said paps were necessary for all women. I immediately became suspicious because my questions were dodged. If it were black and white, why dodge?I approached an epidemiologist working at Melbourne University at the time and asked him about smears. He laughed and said, "well, do you want the truth or the good bits?"...He spent about 2 hours with me taking me through Archie Cochrane's research (he was never in favour of a screening program for cervical cancer using this test and warned them women would suffer if it were introduced).He showed me the real statistics basically my chance of getting this cancer and then the risk of false positives. He said it came down to my level of risk and my willingness to live with the small risk from cancer or a higher risk from false positives and having the test every 2 years. (which I would find VERY unpleasant)I made the decision at 22 not to have the test. It's been a battle, but when you are confident of the facts, it is easier. I was initially denied the Pill and after sending the surgery a polite letter with my statistics, I got my script.I'm not on the Papscreen registry and don't receive reminders. I understand Papscreen are perusing the electoral roll to find "non screeners"...if they contact me I'll politely say I have made an informed decision not to screen.It has taken 30 years for any balanced information on the test and cancer to surface and not much of that is happening here, more the UK. I know Gerry Wain has been outspoken about Australia's over-screening policy and the harm it causes women especially young women. He believes screening should be 3 yearly from 25...still no one is saying women have a choice.I've just turned 52....Margot L
Here is some interesting in depth new information about cervical cancer.http://www.nhmrc.gov.au/_files_nhmrc/file/publications/synopses/wh39.pdfI will quote two interesting facts from the site"The incidence of HSIL is highest among women in their twenties and declines rapidlywith age. Even in the absence of screening, cancer is an uncommon outcome of theselesions. The combination of the uncommon cancer outcome and the falling incidence withage implies that there is a very significant rate of regression.Recent modelling data from the United Kingdom also suggest that at least 80% ofhigh-grade intraepithelial abnormalities will regress without intervention (Raffle et al2003)."I wonder if this information will be shared with the general population. Nic
Here's the 2000 article by Dr DeMay, Should We Abandon Pap Smear Testing?He gives some facts on the issues we've discussed. Don't know if the HPV DNA test was available then, but he'd clearly be in favor of using that test instead of Paps.
My GP thinks Australia overscreens and she doesn't do smears on women under 25. She is English and can't test when she knows it won't help and most likely will send them off worried and afraid for biopsies. She refers them to another GP in the area, but is worried Australia still gives women incorrect information by urging very young women to have smears.She also never pressures anyone to have smears but is very happy to talk about prevention. She thinks the tiny risk can be further reduced by "knowing who you're sleeping with" (their sexual history) using condoms, limiting partners and starting later - no sex before 16 or preferably, 18. In that way, your risk is well below 1% with no smears at all.I love her honesty which is almost non-existent with cervical screening. Oh, and she strongly advises against smoking as she thinks once infected with HPV, smoking might be a factor in progression to cervical cancer because smoking affects every cell in the body.
I was reading the latest issue of Natural Health magazine and there is an article which states what women should do to stay healthy during each decade of their life. For women in their 40s, the checklist includes testing for BP, cholesterol, C-reactive protein and vitamin D levels.And at the very end is the sentnence, "And if you haven't had a mammogram, schedule an appointment with your doctor now."I hate how they tack that one on to the very end and word it in an authoritative, demanding tone. It always comes back to that in every "women's health" article. And there's no explanation of the test or why it's needed or what the possible downsides are.
I don't agree with that straight forward statement, "schedule your mammogram today".It is beyond unfair to make it sound as easy as that...We know that test is controversial to say the least and in the UK there are very senior breast cancer surgeons saying "DON'T have mammograms at any age". One Dr even said he was tired of cutting off healthy breasts.I won't be having mammograms and it angers me that women still get that directive but I suppose that will continue while the "recommendation" is still in place.Sadly, its up to each woman to find the truth and make an informed decision with no help from her Dr (usually) most health websites or the government.Beth
When I did IVF in the U.S. I had to have a mammogram and pap smear before they would proceed. Once again women are held to ransom over these tests. Nic
One thing often overlooked is the question of prevention.Women who do not wish to have screening and risk false positives and excessive treatment could think about prevention.In our society enormous emphasis is placed on screening. We know this is not a perfect test, far from it.I think there should be courses on HPV prevention in schools and brochures printed...I wouldn't want to have an imperfect test as my means of protection.I'd prefer to avoid infection in the first place and turn a very small risk into an even smaller risk. In that way, screening might be more confidently declined.I'm 29 and have had two sexual partners (neither high risk) and I insisted on condoms. Unfortunately there is no test for HPV, all you can do is question your partner on his sexual history. I was satisfied with my partners backgrounds but used condoms as extra protection.I think HPV has been viewed as a problem for women and that is slowly changing, but where is the HPV test for men?You could then easily protect yourself from infection.I don't smoke either.I was frightened off screening after my sister had laser treatment after an abnormal pap at 23 and ended up with an infection. It upset all of us to see her go through that. I firmly believe that treatment was excessive. I don't like what this test does to women. These treatments are serious and a huge worry.I won't let them do that to me.I prefer to make a small risk...even smaller and take my chances.http://www2.cochrane.org/reviews/en/ab001035.html
I have always felt the unreliability of this test and the millions of excessive biopsies supports a profitable industry. Most women are unaware these treatments are unnecessary.I fear a lot of information is kept out of the press to keep this industry alive and well at the expense of healthy women.I saw this recently and wonder how many other articles critical of excessive biopsies might be rejected or suppressed.This worries me greatly.http://www.news-medical.net/news/20100216/Prestigious-journal-suppressing-dissenting-evidence-favoring-unnecessary-cervical-biopsy-industry-complains-HiFi-DNA-Tech-president.aspx?page=2
http://hifidna.com/News%20&%20Events%20files/NEJM%20Dr%20Malina%20%282%29.pdfLetter to Journal...after their decision not to publish article about excessive cervical biopsies.
I have received the following email from a Polish attorney which I am reprinting with her permission. It is minimally edited to correct spelling and grammar.Dear Sir,Having read your article about pap test, I've decided to inform you about a new legal idea, conducted by Polish Ministry of Health. The project of the bill introduces obligatory gynecological and pap tests to all women in Poland in their employment medical tests. These tests are going to be a condition of receiving a certificate of health ability to work. If a woman doesn't agree for a pap test, she will lose her job. Have you ever had similar regulations in the USA? In my opinion this project violates basic human rights and is similar to activities of totalitarian countries, where women bodies were strictly under country control. I would be very grateful for your answer and your opinion about this matter. Sincerely yours,Magdalena Snelaa lawyer from PolandThe pertinent part of my response follows:Quite apart from how appropriate mass screening for cervical cancer may or may not be, making a job dependent on a medical test would certainly be considered a violation of rights in the US unless there was a clear relationship between the medical exam and public safety. That safety could mean the ability to do the job, for example airline pilots are generally held to strict medical standards. Alternatively safety could be the safety of customers. Food handlers may be subject to tests that rule out communicable disease that they could spread such as typhoid. Where prostitution is legal and licensed, they may be required to have regular exams for communicable diseases such as HIV.In the US any work requirements must be pertinent to the job, that is you can't get a job driving a truck if you are blind, but you can't be prevented from working as a teacher because of your gender. Obviously a Pap smear has no relation to the ability to perform any job that I can think of.Any reader comments are welcome. It is clear that Pap smears can be used as a weapon against women in many ways, but this is one way I've never heard of. As I understand it, the Polish regulation is still a proposal which Atty Snela is trying to fight.
Not a lawyer or familiar with Polish political system so not sure how effective any of these tactics would be, but:1) she could lobby that any woman harmed by this compulsory testing (false positives, unnecessary biopsies, missed tumours etc) should have the right to compensation from the employer, as she did not give free consent. Given the high rate of overtreatment, this is a potentially high burden of costs, which will encourage employers to oppose this law. The people planning this legislation probably won't be aware of the downsides of screening and health checks. 2) Humanitarian angle i.e rape victims, or those with gynaecological conditions such as vagisimus who find it almost impossible to have vaginal examinations, will be denied employment. 3) reverse psychology - lobby for compulsory rectal and penile examinations for men as well as a condition of employment (suspect the outcry will throw a pretty big spanner in the works for those trying to pass the legislation). Men suffer from cancer, stds etc as well, and it would be interesting watching those trying to justify forced exams on women explaining why they won't 'ensure' men's health in a similar fashion.Good luck to Magdalena.
A law of this sort means no consent at all.It is horrifying to think that could happen and I agree, these rules and laws are always about our bodies. You could equally argue that men are responsible for cervical cancer because they help spread HPV, yet we don't even have a test for men, but every year there is another test for women.I do think the States and Canada have some of this sort of thinking though. Some pre-employment checks include pelvic & breast exams and screening. I know a woman can't fight in Iraq unless she's had a pap smear. Not sure how that can be justified. I've heard some schools and universities in the States make pap smears a pre-condition of enrolment, although I'm not sure whether that is right. An American girl told me paps were compulsory at her University. (or that was her interpretation of the situation)Also, if you refused these paps, could they and would they do anything about it? Are they just hoping most women will accept the request/demand?Also, many doctors still refuse women birth control until they have the gyn exams and screening, is that really all that different?No pap = no job, No pap = no birth control...both are basic human rights.I really feel uncomfortable the way this test is increasingly becoming a law.It's not even a common cancer, like breast or prostate and they always ignore the issue of over-treatment.I think feminist groups feel unable to act as well, as they were IMO,largely responsible for this mess.Beth
I just read a really interesting article by Anthony Corones and Susan Hardy from the University of NSW in Australia, called, "En-gendered Surveillance:Women on the edge of a watched cervix".The article deals with issues of control, surveillance and the medicalization of our lives and the cervical screening program.I found it quite interesting as it covers historical, sexist and social influences. It helps to explain where we're at with cervical screening at the moment and why screening FOR WOMEN is almost a law (and might actually be a law in some countries before much longer, Poland) and seems to override things like medical ethics, our rights and personal autonomy. It helps explain target payments and doctor made rules making smears a pre-requisite for contraceptive pills and why, for example, a NZ woman might get a home visit from a nurse after she refuses a smear three times while her husband gets no visit even though his risk of prostate cancer is vastly greater than any woman's risk from cervical cancer.http://www.surveillance-and-society.org/ojs/index.php/journal/article/viewFile/cervix/cervix
To put the fear-mongering about a woman's risk of contracting and dying of cervical cancer in perspective, it's instructive to look at the number of deaths caused by medical care each year in the U.S. 200,000 people are known to die every year from preventable medical errors and hospital-acquired infections, and that number is probably a low estimate, because not all deaths are reported. Many more people are injured or sickened each year by medical errors. In contrast, 11,270 American women are diagnosed with cervical cancer, and 4,070 die from the disease each year. Why don't we hear as much about preventing medical errors as we do about preventing cervical cancer? Which one is really a bigger threat to our health?http://lansing.injuryboard.com/medical-malpractice/200000-patients-a-year-die-from-medical-mistakes-and-preventable-infections-according-to-hearst-analysis.aspx?googleid=269142
Elizabeth thanks for that great article. Coincidently I was a history and philosophy of science student at the UNSW about 25 years ago.On the weekend there was an article in my local newspaper about the pill as it is the 50th anniversary of its release this week.The author ended the article by saying that it has enabled women to be in charge of their bodies. I wrote a letter to the newspaper saying that it wasn't true and that doctors use the pill to have women over a barrel in submitting to pap smears. I also mentioned that the behavior of doctors is influenced by the paid incentives. But of course my letter was not published. I believe because of censorship.On a lighter note I just purchased my first packet of birth control pills form an online pharmacy from another country.Nic
I have a question. Does anybody know if there are "kickbacks" for the Mirena IUD? Since I had my baby late last year this form of birth control has been mentioned to me more than once by various health practitioners. My GP only gave me 3 months supply of the contraceptive pill and was keen to mention the virtues of the Mirena. I am opposed to having a foreign object in my body. I had to visit my doctor again yesterday and he said I should consider a more permanent form of contraceptive. I feel that when my 3 month supply runs out he is going to try to persuade me to use the Mirena. However, I do not intend going back to him again as I mentioned in the previous post I can now order the pill over the internet.Nic
Anonymous,Why is your doctor telling you that you should consider a more permanent form of contraceptive? How is that his/her business?If you aren't wanting to have any more children, then I'd seriously consider getting your husband to have a vasectomy. These are MUCH less invasive than ANY female exam, and the new 'no cut' version is really just a hole poked in there & a couple clamps put on. I would love for my husband to do this, as I really don't want any children. But he thinks that I may change my mind someday (he already has a daughter that is only 6 yrs younger than me). Personally I don't use BC Pills because I am very concerned about altering my hormones in any way. I already suffer from period related migraines, and these often are much much worse with the pill.I did look into the different IUDs and was not impressed. There are many many horror stories about not only the pain of insertion, but also of them 'traveling' around and ending up having to have abdomen surgery because they puncture the uterus & surrounding tissues & 'get lost' in there. :(Some women swear by them. If I were willing to do this, I would want the copper T unless you specifically desire hormones for some other reason. The copper T has no hormones, just a metal copper insert that prevents implantation.I would definitely ask around for other opinions. But that's my 2 cents :)
I'm with the last poster.Can you imagine men agreeing to have things inserted into the penis by a Dr before they have sex?I'm amazed what some women agree to and go through just to spare their partners the inconvenience of using condoms or because some men say condoms "reduce my pleasure".I'm afraid any man expecting me to take hormonal birth control every day or have an IUD inserted would be run out the door - how selfish!We take joint responsibility for contraception - he uses condoms and I use natural family planning.I think doctors must get kickbacks, I've had a couple of doctors ask me out of the blue what I use for contraception and then volunteering how great the Mirena IUD is...naturally, I tell them I'd use something like that when hell freezes over.Vivianne
My doctor was only concerned because I had placenta percreta during my last last pregnancy. It's a serious condition and I could have ended up with a hysterectomy. As for IUD's, I googled tumor and IUD and I came across a study in which they put pieces of an IUD in mice. The mice with the IUDs grew a lot more tumors than the control group. I also remember the horror stories of the IUDs from the 70-80s. Personally, I would never use them.Nic
http://caredownthere.com.au/_pages/lifestyle_teenagers.htmlMy teenage daughter has been reading this site.I lived in Amsterdam for 8 years and follow the pap smear guidelines from that country. They don't test women under 30.It frustrates me enormously that Australian sites still highly recommend teenagers have smears after they start having sex, in some cases that could be 14. Doctors in this country KNOW smears don't help these young girls but cause awful numbers of painful and embarrassing biopsies. Yet they continue testing and treating.I can't even complain to the website as they simply say they're following the government and Papscreen's recommendations.It may take legal action to stop this harmful treatment of our young girls and women.These girls probably stay away from testing after an early bad experience and high risk woman have at least some chance of being helped by responsible screening. When will the Australian Government stop recommending pap smears for teenagers? The evidence of harm for zero benefit is overwhelming.These women would have a case against the government - why would they choose to ignore this evidence? Not even the States tests teenagers any more (although some doctors might) and they have had until recently the most extreme recommendations in the world.I wrote to the Health Minister last year and received a patronizing letter telling me they know best.This concerns me greatly and I don't know what more I can do about it. My GP said she wrote to the Health Minister in 1999 asking for an immediate review of our screening program and received a similar letter.Marta
My boyfriend hates condoms and I refuse to take the pill because of the side effects. If I really wanted them I'd find a doctor to prescribe them without an exam. As for an IUD, the thought of something being in there ... I don't know what sick, horrible person thought that up. I'm sure some women like them, but the thought creeps me out. I do believe doctors get incentives for prescibing certain drugs. I went to a doctor who pushed Allegra on me like it was the greatest thing on Earth. All it did for me was make me sleep for 3 days. I have a lot of problems with allergies and such and I snapped when she tried to prescribe them for my allergies to fish and shellfish. Allerga is for seasonal allergies; I was not happy with her. These days you have to be so careful with docotrs. I believe there are some wonderful doctors but there are a lot of bad ones. To some doctors we're just targets and walking dollar signs. So many women (and men as well) are victims of the medical industry. It's like that quote from the Third Man: "Look down there. Tell me. Would you really feel any pity if one of those dots stopped moving forever? If I offered you twenty thousand pounds for every dot that stopped, would you really, old man, tell me to keep my money, or would you calculate how many dots you could afford to spare?"We're just dots.
If it became mandatory women have paps and pelvics in order to get a job would not that be rape? You're not giving them a choice or letting them know the pros and cons of the situation. No exam, no job? They would never think of doing that to men, so why is it acceptable to do to women?I know the US Army makes it a requirement and I disagree with it on many levels. I cannot possibly see how a pap and pelvic could be any use as to how you do you're job. I've had physicals which checked by back, which was appropriate for the work I was to be doing. I can also this being used to control women; I think it would keep a lot of women in the home and out of jobs. The scary thing is I could see it trying to become law. I believe the ACLU would have a field day if it did. And Americans love lawsuits, personally if I were forced to have an invasive exam for a job I would sue or file a complaint with the EEOC on the basis of discrimination. No one is talking about this and the more people are silent the more they will try to get away with it. It's very sad we as a society let this happen. I'm very scared that one day I'll be "forced" into a pap smear. I have nightmares about this subject and I'm literally terrified of having another exam. I cannot see how making women have these tests could benefit them. If I was told I would need to have this done in order to have any job I would 1. Refuse, 2. File a complaint, 3. Sue and go from there. I've been told by doctors that they would not take me as a patient if I didn't have them. My GI said she required all her female patients and I asked do you require penis checks for all your male patients? She said no and I've never been back. Bottom line is, women should not have to live with this fear. It's morally reprehensible
A double standard certainly exists and this forum is helping lots. One of the most effective weapons used against women is the brainwashing that has taken place with this screening - women literally fear saying anything negative about testing and certainly few would admit they don't have or want smears.These things are a try-on in my opinion and any complaint would mean they'd let you off the hook. They hope most women would fear complaining and facing public condemnation, "What! You don't want smears, are you insane?"...and suing might expose you to widespread criticism.This is a serious concern and one men don't face. Women have been turned onto other women to take freewill out of the equation.I've seen the venom over the years...statements like, "Well when you die of cancer you'll be sorry"...the emotion is huge and you forget you're talking about a cancer screening test that should be a choice.Screening could never become a law and any company that required those checks could be challenged...they know most women will accept the checks or do it for the job, but object and they'll let you pass. (except in countries like China where civil rights can be ignored when it suits the administration)The Americans are bad at "requiring" these checks.I've had no trouble in Australia or the UK. When I joined the Aussie public service the health check was basic, certainly no breast or gyn exams.The States were different though...I was "required" to have a full gyn exam before I could participate in a work transfer program...a year in California.I refused the routine breast and pelvic exam on the basis they are not recommended or done in Australia (got a letter from my Dr) and pap smears on the basis they require informed consent and carried risk. (I didn't mention I was low risk because I don't think that's their business, I hate discussing my sex life with everyone who pushes smears at me)I was asked to sign a waiver and if I'd come down with any cancers that affected those areas while I was in the States they didn't have to cover my medical bills. Fair enough, I could just fly home and use my private medical insurance.I think the acceptance of annual gyn exams for women, the power of your insurance companies, employer provided medical insurance and the high risk of litigation sets the States apart and explains a lot of the "requests".I still think refusing and signing a waiver would succeed.Of course, women who lack confidence might choose not to work, volunteer or take up opportunities and that sets us back a century or two.It is telling that men don't seem to face the same problem...particularly when testicular cancer occurs as often as cervical or almost and prostate cancer is very common. (although largely confined to older men) But then cervical cancer tends to occur more often in older women too. (and even then it's far from common)Judith
Also, I think your insurance companies can dictate to you as well.Can your insurance companies require you to have smears and mammograms before they'll insure you?If so, what about risk? Do they accept responsibility for false positives and unnecessary treatment?Here I take out private insurance and make my own decisions. If I go into hospital, I make a claim. I'm covered for all types of surgery...no conditions set by the insurance company.But I've heard in Germany the insurance companies may increase the premiums of people who don't screen or reject their claims if they get breast cancer and haven't been having mammograms for example...When these things carry risk, I just don't see how they can get away with that.
Anon I think if the insurance companies are going to force you to have screening then they should agree to pay compensation for pain and suffering if you get a false positive. Nic
To add to my last post, if you are for forced to have pap smears by your insurance company, make use of their psychologist coverage for anxiety. Make it very expensive for them to make pap smears compulsory.Nic
I found the article linked by Elizabeth very interesting.I studied sociology at University and found after that course, I looked at cervical screening and the way it influences and affects women closely and critically.One article that alerted me to the negative affects this screening has had on our lives was,"The art of surveillance or reasonable prevention?" by Linda McKie from the University of Aberdeen - published in,"Sociology of Health & Illness" Vol 17, No 4 1995 ISSN 0141-9889 pp. 441-457The paper includes the following statements that I identified with strongly.At the time I was defending my non-participation in the program and feeling very isolated and threatened. My one partner was a virgin, a real one, I have no doubts. I know I've never been infected with HPV, but why do I need to convince a Dr and plead my case at every visit? Why is a simple No unacceptable? Why do I feel guilty and feel flustered talking to doctors? Why do I now avoid doctors even though I know I'm in the right?Anyway, I wanted to highlight these pieces."This screening service is both creating and reinforcing a surveillance of women's sexual lives and health" pg 441"There are a range of risks with screening. These risks are both physical and psychological...anxiety and stress caused by the taking of the test and any wait for results; concern at social sanction on diagnosis of a positive smear; inaccurate interpretation of smears and distress caused by treatment for abnormalities which if left untreated may not actually progress to cancer. The cumulative costs of screening over a lifetime are high and the invasive nature of the test is unacceptable to many women. (pg 444)Feminist theories - "theories of emancipation are often blind to their own tendency to dominate and impose a new hierarchy"Have you noticed feminist groups always advocate screening for every woman and never support the notion of informed consent?I received no support when I complained to a women's health action group."Given the apparent link between sexual intercourse and cervical cancer....details of sexual activity, when requested, again assume a series of social relations and social sanctions. The link between early sex and cancer means this admission can result in derogatory comment.Heterosexual men are involved in the transmission of HPV, yet men are often excluded from any surveillance of their sexual activity.""Women's sexual activity and cervical health are utilised as mechanisms for the operation of power over women." pg 453Women are encouraged to attend every 3 to 5 years. Increasingly that "encouragement" is becoming surveillance of numbers for the attainment of targets. Tests are taken in medical environments which are regulated by unequal power relations between the professional and female patient. Women may have to outline their sexual activity. Point made:Control of women's bodies reflects traditional aspects of patriarchy.Screening encourages moral policing of ourselves.The screening service creates and reinforces negative views of women and female sexuality. p453Is this screening a reasonable means of prevention or a means of surveying and policing women's sexual activity?Does the program undermine women's self-esteem?"Screening has taken on a financial and political dimension in which the individual, especially the non-participator, is problematised and the problems (of screening & risks) are largely ignored. pg 454This is a much needed forum. It's nice to finally see this program being discussed, THAT empowers women to fight back!Thanks Dr Libby Whttp://www3.interscience.wiley.com/journal/119244793/abstract?CRETRY=1&SRETRY=0You can download the entire article free of charge.
It's all a part of modesty. Not only do I vehemently oppose the invasiveness and the embarrassment of a pap smear but I also resent the assumption that I should discuss my sexual life with a doctor. It is between my husband and me. I may have issues but I don't care, I don't need third party involvement. I see it as prying.Nic
I read that a urologist gave a man the Digene Hybrid Capture® HPV DNA Test on a penile urethral swab to detect HPV infection. Dr, are you familiar with this test?Is it now possible to ask a man to take this test to prove he hasn't been exposed to HPV?I hope so, looking for a virgin is proving difficult.I'm a 26 year old virgin and most men my age or older have had quite a few partners. I would prefer a pap smear/LEEP/conization free life.
I like Dr Fitzpatrick...here he talks about screening creating a nation of fearful and anxious people in a climate of over-diagnosis and treatment.Couldn't agree more...http://www.spiked-online.com/index.php/site/article/7120/
I cancelled the surgery. Not only would I have to undergo the 12-lead EKG, but would have to be dragged in a gurney in a transparent paper gown!!! No underwear was allowed, you would be knocked down and there would be at least seven people in the OR- four of which would be male, all that for an eyelid surgery... I beg somebody answer, if you're slender, well shaped, very tanned and relatively young, are you sure they don´t notice?
Maria, In one of those Reader's Digest articles that they do "Ten things your doctor wouldn't tell you". One of them was an admission that as most of doctor's patients are older, they really love it when a young attractive patient comes in.Nic
Here's another interesting thread of women discussing having leeps etc. http://www.essentialbaby.com.au/forums/index.php?showtopic=730525One woman had a miscarriage at 5 months because of an unnecessary procedure. Of course she doesn't realize that.Nic
I had a hysterectomy after an abnormal pap smear when I was 19. I was not sexually active but don't think doctors believed me. It is a long time ago but I was told my smear was very abnormal.I've been reading through this blog and one other and feel my hysterectomy was unnecessary.I've never been able to get to the bottom of my surgery and its only been in recent years that some of this information has been released to women.I've found out a few things that make me think my surgery was unnecessary.1. The rareness of cervical cancer in virgins.2. The rareness of the cancer in young women and teenagers3. The revelation that young women have abnormal smears when they don't have cancer or pre-cancer. I'd never heard of a false positive.4. The latter is such a problem, young women are not screened in some countries and,5. Some doctors say screening does not work in young women. By young, I mean those under 25.I have mixed feelings. In those days not enough was known about this cancer and its development and progression BUT, why was this test done when that was the case? It was never presented to me as a risky thing.I had no symptoms, it was included in an annual physical when I reached 18.I've never married and obviously have no children of my own and I've never had sex. The end result was a mental switching off with that area, a negative feeling about sex because I'd been asked about my chasteness, a fear of rejection because I was sterile and the fear I might relapse and die early.These fears have shaped my life. My youth and innocence and the chance of a normal life was taken from me. I say normal because I wanted to get married and have children. The whole thing was hellish as well as the problem of early menopause.I was terrified I'd die from cancer. My parents didn't ask the doctors any questions. Not much was said after the surgery. In those days doctors were all Gods.I have gone through life thinking I'm a cancer survivor. I don't think I am.This blog has been very helpful to me. I wonder how many other women went through the same thing.There is so much we don't know about this testing and cancer. This blog seeks to correct that imbalance.My thanks to Dr Sherman and all posters.Margaret PS. I see in Mexico that doctors are doing hysterectomies for low and medium grade dysplasia. My reading says most dysplasia is nothing to worry about and only high grade needs watching.http://www.guttmacher.org/pubs/journals/3109695.html
Margaret, How awful!! Can you get your pathology report? Wow. It reminds me of the story the author Dr Stanley West talks about in his book "the Hysterectomy Hoax". Have you read it? You can get it from Amazon. He tells the story of a 19 year old having an unnecessary hysterectomy. Even worse the doctor didn't even tell her she had one. She thought he was just going to remove a cyst. I don't know when you had it done but doctors really didn't understand what they were doing at the time it seemed. Although if they had any common sense they couldn't possibly have believed that all those false positives were going to be cancer. Did they think that the incidence of cervical cancer suddenly increased massively with screening? You know what I mean? A doctor rarely sees any patients with cervical cancer but then when screening is introduced, 1 in 10 women suddenly potentially has cancer? Ridiculous!I wonder how many more lives Dr Papanicolau has ruined. I think it definitely has hurt more women than helped.Nic
I think the realization that Margaret has come to will be shared by many others. All the young women who in decades past have undergone cone biopsy and even hysterectomy must now be puzzled by the new recommendations which state that they shouldn't even have been tested at a young age. When they research the issue they need come to the unmistakable conclusion that they almost certainly didn't have cervical cancer and their worries, troubles and sacrifices were for nothing. It is a sad history which has not entirely ended for present day young women.
My surgery was in 1961.I did contact the hospital about a year ago and asked for a copy of my medical file or pathology report, if it were still filed away in their archives. I heard nothing for 6 weeks and then got a call from their legal people asking why I wanted this information. They didn't think it would still be around anyway.I guess they fear legal action but at this stage of my life, what good would it do me?The stress would probably shorten my life.I would have liked a definite answer.It was early 1950's when women where told to see a gynecologist every year for a pap smear. (some women were having them earlier with their general physician.) My sort of case was probably most likely in the 1950's and 1960's.I know some doctors in the 1950's and 1960's even thought a hysterectomy was a sound idea after childbearing. That way the risk of a few cancers was removed. I've read that around two thirds of all hysterectomies at that time were unnecessary. Even today there are too many hysterectomies. It's a safer surgery now, and that may be why the numbers are higher.Getting educated and being firmer with our doctors can help protect us from many of these things.I hope many women of all ages find their way here.I feel relieved that this information is here for them.Margaret
Can anyone give me a reference on HPV and virgins?My doctor says I must start having smears even though I'm a virgin. (I'm 21 and have been avoiding smears for 5 years)Even though I've never had any sort of sex, my doctor says holding someone's hand can be enough if he's infected and has it on his hand. In other words, HPV isn't only on the genitals but can be on the mouth, hands, anywhere.Is this true?I heard that HPV is linked to sexual activity, not just intercourse but sexual activity.Also, the well woman exam. Are they really necessary without symptoms? If so, why don't English doctors do them? (I have an English friend I met online and they don't have them)I'd prefer not to have them unless they are of major importance.I don't have any medical or gyn problems.Thanks!Kat
Kat,Here's an answer to your question from the Mayo clinic.Your risk is vanishingly small.
Dr Sherman Why have you provided a link to that? It goes against everything we have been talking about. And the information is not correct. Cervical cancer is not related to family history!Kate I am in Australia. I have never heard of the well woman exam. We do not have them. But you see the problem in your country you have gynecologist as your primary carer. We don't. We go to our GP. We only go to a gynecologist if we have a problem.Nic
Nic,I just posted the link for the opinion that virgins don't need Pap smears.However there is some evidence that cervical cancer is more common in some families than others. HPV is still needed to precipitate precancerous changes but some heredity may make malignant transformation more likely. I don't think the issue is settled.
Have they looked at possibility that similar types of high risk behavior usually runs in families?Nic
The pressure on women backfires later on when women don't need birth control and can't be blackmailed by doctors.If every woman felt like she was making the decision and making an informed decision perhaps, screening might work.As it is when women are blackmailed, threatened, scared, coerced or forced to have them, a number of them will end up deeply resenting the manipulation and regardless of their level of risk will walk away.I have a few friends who have walked away and one openly told a Dr that she has been raped for years. In her words, when doctors can force you to have an invasive screening test that should be optional, TO GET PILLS, that's rape. I guess legal rape because there are no consequences for doctors and it is such a common practice, it's the norm.Also, I guess women CAN walk away and manage without pills.When screening empowers doctors to use these weapons against women; how could any fair person say that's right?One high risk friend has stopped testing after two negative cone biopsies and 2 or 3 normal punch biopsies, who could blame her?Of course, all the biopsies were in her teens and 20's when she was least likely to have cancer and now she's older and the risk is greater (although still small) she won't screen.If she'd been left alone when she were younger, given truthful info and made her own decisions...she might have agreed to some testing.I think even 3 or 4 tests would give a high risk women a great deal of protection. I've read even one smear at 40 is enough to reduce the risk by a fair margin. Our doctors are not serious about this cancer - if they were they'd be working WITH women and offering alternatives like self-test kits. (used in some parts of Europe) One friend was sexually assaulted as a child and she will never test. Self-testing every decade would give her some protection but would also minimize the risk of a false positive. That sort of treatment would be a huge ordeal for her. Annual testing would put her in day procedure and that would be the end of testing. You can only blackmail women for so long. The current conduct by doctors and NP does not set women up to test for life, it causes emotional damage, physical harm and deep resentment.Its taken a long time, but more women have had enough, fewer women are grateful for this intrusion into our lives/bodies and more women sound educated on the topic and are criticizing the lack of informed consent. (perhaps, your rare & helpful article, Dr?)Once those comments were rare.I saw a website recently where a pro-smear academic asked for responses to a patronizing Q: Is requiring a smear for birth control coercion or did this rule make you proactive with your health & establish the test as a normal part of your healthcare?I'd say about 95% of the comments are negative. Clearly not what the author was hoping for, but to her credit, the thread hasn't been deleted. Another thread shows the long term damage of virgins being forced to have smears. (a ridiculous practice that seems to be confined to the States)I think forums like this are giving women power...that is, food for thought, the facts and enabling them to fight back or continue testing in a sensible manner that protects them from harm.It is sad that this sort of information has been unavailable until now, but something has changed...maybe one person speaking out and others supporting them and offering their views is changing things for the better. Fewer women are feeling grateful after a second negative cone biopsy.I don't know many woman who have made an informed decision to screen, we either avoid screening for all sorts of reasons or submit through fear, intimidation, coercion, it's "required" or in the mistaken belief this cancer is common and the test is rock solid. I'm pleased things are changing.Tara
Here's a disturbing article the covers many topics that may be of interest to readers on this thread. It's written by a female doctor and describes her personal experience as a patient: http://www.kevinmd.com/blog/2010/05/patient-apology-money-medical-malpractice.html MER
New research from the Nordic Cochrane Institute:A review of data over 10 years for two groups of Danish women,ages 55-74. One group having regular mammograms, the other, no mammograms.The findings: In women who could benefit from screening (55-74) they found a mortality decline of 1% per year in the screening areas.In the non-screening areas, they found a decline of 2% in mortality per year.The research was recently published in the BMJ.Needless to say not everyone agrees with the findings - there are various comments posted after the research in the BMJ together with responses from the researchers.(Karsten Jorgensen, Per-Henrik Zahl & Peter Gotzsche)http://www.bmj.com/cgi/content/full/340/mar23_1/c1241
We keep getting scary stories that HPV is an epidemic and there will be an explosion of cervical cancer in teenagers and young women.The facts don't support that theory but people reading these articles don't know that...I read this article in Time magazine and having read this thread was more aware of what HPV actually is and how it only progresses in a small number of cases.No wonder women are terrified of this cancer and allow over-testing, reading articles like this would scare the life out of anyone.Our doctors do exaggerate the risks. An ex-GF was scared to death after being told she had HPV and delivered in a way that made it sound like a death sentence. She saw a Dr in London recently (she's working there) and raised her HPV.She was relieved to be told that HPV is very common and cervical cancer is rare. She was also advised NOT to have 3 monthly smears as advised by her doctor and to forget about LEEP at this stage. She feels happier now and angry that she spent a year fearing she'd need a hysterectomy in the near future. You have to wonder why our doctors behave in this way? I guess it's fear of legal action.Anyway, I went looking for answers after speaking to her. Thanks for the information that confirms the UK advice.Isn't it sad we have to look overseas (or at this forum!) for straight information?http://www.time.com/time/magazine/article/0,9171,967127,00.html?promoid=googlep
Anon, I note that article is from 1988 and hopefully would be retracted nowadays. It is not written by a physician.But yes the article is scary and downright wrong. It says that between 5-15% of HPV infected women with genital warts will develop cervical cancer. In truth it is believed nowadays that the strains of HPV that cause warts are not associated with cancer. And there is no evidence I know of that the frequency of HPV is increasing. It has likely always been high.
Dr Sherman,Is it ethical to pay women for smears?I read on another forum that a Clinic in Hamilton, NZ is paying women for smears and is apparently, being permitted to do so by the Medical Ethics Board.Of course, NZ has a program for performance payments for smear tests, otherwise no Dr would be interested in paying women for smears. The target payments makes it profitable.Ruthhttp://www.stuff.co.nz/dominion-post/national/3737555/Clinic-gives-10-for-vaccinations-and-smears
Ruth, it's not just smears, but vaccination against HPV is the full goal. As the article itself says, ethically it's a grey area. Certainly there are other instances I'm aware of where small payments have been used to encourage public health initiatives. If the intent is to do vaccinations and smears in young girls (which is the group that the vaccine is targeted to, then it is certainly medically unethical as smears are not indicated in girls.If it was the US, I'd bet that the vaccine manufacturers were subsidizing the campaign and paying the $10 (to widen their overall profits). In New Zealand I have no idea.
Here's a brief summary outline of cervical screening guidelines from the 3 American organizations that publish guidelines, ACS, ACOG, and USPSTF.They are not identical and can be easily compared in this format.
Very interesting chart, but it fails to mention informed consent or risks. I know, I know it's about recommendations, but cancer screening is more than just recommending getting tested. They distinguish between age and some other factors, but it still makes the blanket assumption that all women need screening (until a certain age). No choice, just have them do it.
Dr, wouldn't paying for smears or even rectal exams in men violate informed consent because some may be motivated purely by the money?If a man had a rectal exam and was left with problems after a biopsy that was normal, wouldn't that be dangerous for the Dr and the government that made the payment?We looked at public health objectives in a subject at Uni and ruled out payments to get men to have rectal exams (before the PSA test) because it was thought unethical to influence someone's decision about screening with money. The disadvantaged would most likely take the offer and might be further disadvantaged. Screening is no guarantee of a good outcome, most have an uncomfortable and embarrassing time of it, others are left injured or even dead (colonoscopy and ruptured bowels) therefore it needs to be a level playing field.There is always a tension there though when govts pay millions to start screening programs.Jack
Jack,Much drug research is done with volunteers who may be paid in a variety of ways. That has no relation to informed consent which is required in the exact same way whether the treatment is paid or not.For some reason, informed consent seems to be ignored for Pap smears. Paps are treated like they were a minor procedure such as drawing blood. There is no present day rationale for that as Pap smears can lead to many further invasive procedures, most of which turn out to be negative. Pap smears originated in a different era when no one considered the negative effects of screening campaigns.
Dr, do you think we can change the attitudes doctors have about cervical screening?Can you see the day when a refusal won't lead to hysterics and high drama?What is the fastest way to effect change?I read on another site that this cancer affected 14 women in every 100,000 before screening and now affects 6.5 per 100,000. Other things probably helped with the decline as well.When our brochures say, "since screening there has been a 70% drop in this cancer" that sounds a whole lot better than 14 women down to 6.5 women per 100,000.Aside from the misleading impression it gives us, the money could be better used elsewhere on skin cancer or mental health programs. Both areas are underfunded and many more people die as a result.Rose
Rose, there's no easy solution. You have to be proactive and be prepared with the facts if anyone tries to pressure you into a Pap that you don't want or need. If more women would protest, doctors would get the message.Of course it would also help if women who have been unjustifiably injured by cone biopsies and LEEPS would sue. Has to be a current case though not an incident of 20 years ago when standards were different. I would think that any young woman (<21) pressured into having Paps and procedures nowadays that turn out to be negative would stand a good chance in court. That scenario is at least the most obvious, though many others are possible.
http://www.riversideobgyn.com/healthwell.html#debateI was surprised to see this group are still recommending annual paps and mammograms if your insurance covers the cost. The motive sounds financial to me.They also recommend breast self-exam. Now breast biopsies are no fun and I know one breast surgeon who lists "biopsies" as one of the risks for getting cancer. This is reckless and bad advice. Who is protecting these patients?They are only looking at the remotest possibility of cancer "we've both seen a case of cervical cancer in this age group" meaning teenagers.There are freak cases in all areas but you don't treat everyone on that basis.They don't seem to give any thought at all to the discomfort many women feel having these tests, when fewer would be better nor do they care about false positives and bad outcomes.I'd never go to a Clinic that proudly boasts they ignore guidelines and do everything they can to hurt you.I think it's arrogant, harmful and profitable excess.They're also pushing the annual gyn exam that is dead in the water as far as I'm concerned...they'll have to accept their income might drop in the future. No woman should have those exams just to keep their profits high.The sad and shocking thing is that most women will follow their advice.The search continues for a Dr who practices evidence based medicine.Jasmine
Dr. Sherman:I was moved by the post of the lawyer in Poland... That is exactly what I was talking about... I live in a developing country where our ex-president was an oncologist, and Paps are mandatory here or no job. Seriously, you cannot get absolutely any job or go to University, or even highshcool, among other things. Luckily we can get over the counter BCP, or Plan B. To make matters worse, everyone is brainwashed. Doctors are paid, of course, screening targets, but they´re also hugely paranoid about being sued. OK, I think we then should make real what they`re sooo afraid of: women worldwide sould sue them off their pants for false positives and conizations. If legal action is the only way to make them come to their senses, so be it....Do you envision any other way OUT OF THIS LUNACY?
Keep in mind a lot of women still want breast and pelvic exams along with their yearly paps. I don't want them taken away nor do I want insurance companies to stop paying for them. I respect the women who don't want them and those that do. Your body to do as you please but I prefer neither side making that choice for the other.
Actually Anon I beg to differ. I was one of these women who thought I needed a 2 yearly pap because that was is recommended in our country. So I went along voluntarily even though I hated them. I assumed like many other women that it was a common cancer because not one health provider ever provided the facts. Now I finally have the information and I know I am very low risk so I will perhaps have one more in 10 years when I turn 50 and that will be it. I assume my friends all of whom hate them with a passion too will stop having them when they know the odds and risks.Lou
Lou, You must be Australian.I predict the govt will be forced to finally change screening guidelines later this year or next year. After the changes made to the American and UK programs, our program stands out as excessive.The over-screening of Australian women sends 77% for colposcopy and usually some form of biopsy - that is VERY serious over-screening/over-treatment for a tiny risk. They also continue to screen teenagers and women under 25...basically they screen 2 or 3 years after women become sexually active.The evidence of harm for no benefit in women under 25 has been clear for years. The serious harm caused by over-treatment is undeniable.It still amazes me that these issues have been so effectively silenced in this country.I've only read a couple of critical articles over the years. Almost all women have been completely misled as to the value of this testing and most are unaware of the risks and the uncommon nature of this cancer. IMO, there is no informed consent in Australia.I spend half the year in the UK and although the pressure to screen has always been a LOT greater in that country, issues of informed consent and risk are in the papers a fair bit, especially over the last 5 years. This makes it easier for women to defend themselves from doctors chasing target payments.I can only think of one Australian senior Dr who has expressed his concerns at the overscreening of women and continuing to screen women under 25 when it is of no benefit, but causes great harm.In the UK there are 12 or more that come to mind...all senior and outspoken.I feel a bit sorry for the sole Aussie Dr - he's seriously out-numbered by the screening zealots.They always express "surprise" and "concern" at his comments in light of the "huge success of the Australian program in reducing the death rate from cervical cancer by 70%" (or even up to 90% - don't let the facts get in the way of a good story!)Never a word to address his specific concerns.I call it success in a vacuum, deaf and blind to the facts - just look straight ahead and never at the carnage that surrounds you!
Yes I'm in Australia. I wouldn't be so angry if it was just a blood test. But I cannot believe that whoever formulated policies on these tests never took into account the invasiveness of it. I cannot believe all the stress and anxiety I went through in having them was for something so rare. I suppose they knew most women wouldn't bother letting themselves go through such humiliation for such a rare cancer and so have managed to keep the odds of getting them a secret. We all hear about the odds of getting breast cancer, especially when they talk about screening and checking, but we never hear about the odds of getting cervical cancer. I should have smelt a rat then.On a side note I was reading a young doctors blog one day. And he wrote about an incident when he had to insert a speculum in a woman. He then claimed that as soon as he inserted it it shot out and he didn't know what had happened. He then said the nurse with him told him that the patient just had an orgasm. Now besides this doctor obviously being a virgin and having no idea what makes a woman orgasm, it just angers me that he would even suggest that this is a pleasant experience for any woman. Only a man could have invented the speculum.Lou
This forum is wonderful, fabulous information!I'm a very reserved person and the thought of having gyn exams every year made me put all of this out of my mind.I saw a GP for general things but she was always very busy and didn't have time to quiz me about smears.Thank goodness, I didn't agree to this testing. How can any Dr or governement explain the large number of biopsies for a cancer that affects 1% of women? I think one paper on the Violet to Blue site said 1.58%, still, hardly a common cancer.If you're going to screen for one of the rarer cancer, surely you're ethically obliged to use a reliable test?Is it the case that having a pre-cancerous stage means doctors can prevent this cancer in most cases and therefore they think the downsides are worth it?But if it's uncommon, shouldn't women be told of the risks and odds - the odds of having biopsies is very high, the odds of preventing cancer fairly low. It can't be more than 1 or 1.58% because it doesn't happen more often than that...Certainly the stress and fear even testing (let alone treatment) causes many women is probably bad for their health and not worth it for such a small risk.
These questions were asked 10 days ago by Rose. I'm remiss in not attempting to answer sooner:Dr, do you think we can change the attitudes doctors have about cervical screening?Can you see the day when a refusal won't lead to hysterics and high drama?What is the fastest way to effect change?Change usually comes slowly unless it's effected by changes in law or lawsuits. Presently you have to arm yourself with the facts when you see a doctor. Bringing along printouts is helpful, especially if your doctor is one who doesn't honor the new guidelines for every 2-3 year Pap smears. If enough women would do this, doctors would quickly get the message that they can't bully their patients into unwanted testing anymore. Changes are being effected slowly due to changes in guidelines and greater awareness of the issue helped by these sites.
Here's an article on ABC talking about over screening for a variety of diseases. Cervical cancer is mentioned in passing.It's a good sign that the problem is beginning to penetrate into the mainstream mass media.
Dr, what is your view of an 84 year old woman being screened yearly for cervical and breast cancer? (pap tests, pelvic and rectal exams, mammograms & CBE)Are they of any value at all?It appears to be near impossible to get an adequate pap test and my poor mother-in-law ends up having about 3 samples taken every year.My sister-in-law feels her medical insurance will be compromised if she doesn't have all these tests. I couldn't get a straight answer from the insurance company or our Dr. I don't know if that's right but even if they uncover a problem it's unlikely to be aggressively treated.Most people are not prepared to criticize cancer screening, more is better, but common sense must play a part and free will.My mother-in-law wanted to quit years ago and suffers through all of it. Her carer thinks she should have everything because medical care is important at every age. I'm not writing-off my MIL but surely enough is enough at a certain age say 70?One doctor told me he still screens all his female patients regardless of age and sexual activity but might go to 2 yearly pap test after several normal results. (but annual for everything else)No one seems to want to tackle a cut-off age for these tests and while recommendations remain confusing, some say yes, others say maybe, it means the testing will continue.Is it up to us to call a stop to the testing and forget about conflicting and confusing recommendations and disapproving murmurings from her carers and doctors?Lillian
Lillian,I can only quote you general US guidelines. If you've had several negative Paps you don't need any more after the age of 65-70. You can get more information on that from the links I give. If her Paps are not negative, I could only suggest that a HPV DNA test might help to assess better her current risk. I really don’t know any recommendations applicable to a patient from whom adequate Paps have not been obtainable. In general, at her age her risk is likely very small if she has not had problems before.Never heard of any insurance company refusing coverage because a patient has not followed advice. I wouldn't worry about that.
Lillian, That is absolutely ridiculous! Leave the poor women alone! What an awful way to spend the end of her life. Pap test are awful for postmenopusal women as it is near impossible too get a good sample. Most other countries have a cut off at 60 -70 for pap tests. I don't need to tell you more, all the information is here and on other blogs linked from this site. And stop all the other tests too!Nic
Thank you Dr Sherman and NicI've looked at a few of the articles linked here and taken your advice on board and feel the exams and tests should stop. She could have a general exam and will have any symptoms attended too, but that's all.Now to convince other family members and her doctors. Thanks so much for your advice.Lillian
http://www.stripes.com/news/military-officials-to-stand-by-women-s-testing-guidelines-1.96832So many groups are ignoring the recent changed guidelines. Those changes were designed to protect us, yet doctors are not following the advice of these expert groups.This Dr says he can discuss biopsies and their risks when the women has a problem with her mammogram, that is not good enough - how many women are happy to leave something "suspicious" at that stage?If they're not recommended by a panel of experts, I don't want to go there. It's totally unrealistic to say the woman has a choice at that stage and these doctors know that.I know money and profits are a factor, but surely legal liability is less of a concern if the Dr is following guidelines?I tend to lose respect if a Dr pushes excessive tests and exams, I become suspicious of his/her motives because I know it isn't about my health.Mandy
http://www.carepages.com/cancer/cervical-cancer-and-virginity.htmlI found this offensive...a Dr says they say all women including "virgins" should test at 21 "because not all women are honest about sexual activity".When did doctors become our moral guardians?The arrogance and paternalism is bad, attitudes need to change.
I noted this site in passing. It's a thread on cervical cancer with all the usual types of articles. But also included is my article on informed consent, presently the last citation on page 1.It's a good sign that the topic is beginning to be recognized on a mainstream non controversial health blog on cervical cancer.
It makes me think that one person can make a difference...things slowly snowball.What I'll never understand is why it took so long and how they're still getting away with it when the facts are so different to the "facts" given to women.Two versions of the "truth".I know a few women who now question the need for all the tests they've had over the years and many have also had biopsies. It really is scandalous to do that to women without informed consent. Made worse because all these things involve major violation and harm to private areas of our body.Ruth
Ruth it took so long because we needed the advent of the internet to inform ourselves. It's so sad that we have to rely on lay women helping other lay women with a few good doctors like Dr Sherman as well, to learn the truth. You know I read on a blog somewhere that before people had access to medical research and information via the internet (not just the heavily censored and biased info that your doctor or governments will tell you) is like when the clergy had all the power because the average person was illiterate and only the clergy could read.
Here's a brief article based on a UK study. The point of the study is that cervical cancer rates have not gone down in the past 30 years despite better screening because today's women have had 3 times the number of sexual partners as their mothers did. -An interesting finding.
Or maybe CC screening doesn't work. They didn't bother to mention that possibility.
This of course is just a short newspaper article and not the original study. So other factors may have been looked at.But honestly it is not in dispute that screening does reduce the incidence of cervical cancer. It is not the only factor but it is safe to say that when widespread screening has been instituted, the incidence of cervical cancer has gone down in every country. If anyone has contrary info, please post it.
The evidence there is screening doesn't change the outcome for women under 25. It has no effect on the death rate. The rare case tends to be missed by smears (usually because it's an adenocarcinoma) but vast numbers have unnecessary interventions as abnormal smears are very common. (caused by HPV infections that the immune system usually clears within 2 years or the smear picks up normal changes that occur in the premature cervix)It infuriates me when I read that young women have many "lesions" detected on smears, but they never say almost all are harmless - the inference is these lesions would become cancer IF NOT for intervention.http://www.abc.net.au/news/stories/2009/07/29/2639776.htm
Sorry, my point about that article.These woman may have had more sexual partners than their mothers, but screening won't have an impact on the death rate from this cancer in women under 25 (or even 30), multiple sexual partners or not...it simply doesn't work and causes great harm.
Oh I agree Elizabeth. Screening works in general but not in some specific age groups. Young women in particular should not be screened, and screening needs to be restricted in women over 65-70.In general I'm not against screening, only against forced uninformed screening. The risk of cervical cancer is not compelling for the vast majority of women. The decision to screen should be your free choice.
Here's a discouraging report that will come as no surprise. Most American doctors are not following the new guidelines for Pap smear testing.The article also states one recommendation that I'm not familiar with, that a woman can go 3 years between negative HPV DNA tests regardless of her prior history.
I have now obtained and read the article referred to above in the current issue of Archives of Internal Medicine: Arch Intern Med. 2010;170(11):977-986.The article is not available freely online, but is widely available at any medical library and worth reading.I didn't realize that the USPSTF has for years recommended that Pap smears need only be done every 3 years if they are negative irregardless of sexual history. That's an official guideline that no one seems to follow.Beyond that the paper documents that only a third of physicians follow stricter accepted guidelines that is, after 3 negative Paps, no further screening is needed for 3 years. Worst over users again turn out to be Ob-Gynes to no one’s surprise. The newer HPV guidelines are perhaps not widely accepted yet, but are likely to be. A negative HPV combined test clearly means that further testing is not needed for 3 years.How many of you ladies are still being pushed for annual exams following negative tests?
Dr, thank you for asking! Not many doctors seem to value our opinion. Anyway, because I was aggressively being pushed into having paps and it just made me not to go the doctor.Personally, I don't go to the doctor unless something is wrong -no 'check ups' what so ever; I trust my body. Literally every time I went I was told I 'had to' have these exams. I think it's sad I can't go to the doctor without being harassed. I also have asthma and food allergies; I feel like I can't even get a new inhaler or epi-pen. Besides the pap smear talk they also say it's a requirement to take a pregnancy test before being prescribed these meds. No matter what doctors just can't focus on actual problems women have -it all goes back to our reproductive organs.Currently I have a inhaler about to run out and no epi-pen -nice to know a hypothetical life is more important than mine.
Dr, here we have an 18 year old girl who has a normal smear (she shouldn't have been tested at all) and 2 months later has another smear which shows "moderate dysplasia". Her Dr has recommended LEEP.I find these sorts of stories terribly sad and it makes me angry. Who is protecting these young women from harm?When a Dr is prepared to do LEEP on an 18 year old asymptomatic girl something is terribly wrong.I'd hoped the new guidelines would reduce this sort of thing happening? Hopeful more doctors would see the danger of acting against the guidelines?It seems many doctors are carrying on as before....Women must be alerted to the danger of simply agreeing to the test and treatment.The evidence is clear, yet this continues.This poor girl will probably believe her life was saved by this amazing Dr and never be the wiser - even if she ends up having problems later in life because of damage to her cervix.It really is a vicious cycle.http://forums.webmd.com/3/gynecology-exchange/forum/16343/1
I agree Elizabeth. At the very least this young woman should obtain a second opinion before having anything done. Has she been told that the risk of cancer is around 2 per million in her age group whereas the risk of long term complications from LEEP is hundreds of times greater?I note your response. That is indeed valuable. All of you can make a valuable contribution by challenging these kinds of discussions on other blogs when you can.
Dr, thank you for this opportunity to speak candidly about this test.I'm 28 and have never tested. I'm not satisfied with the scant literature I've been given and will not agree to any procedure unless I feel I've been able to make an educated decision particularly when my health is excellent.It means no birth control pills but we've found another way of avoiding pregnancy. I did try HOPE but the pressure became great and upsetting and I stopped seeing them 2 years ago.I don't like seeing doctors because of this test and the never ending pressure.It's almost an hysterical reaction from doctors. My father has refused bowel and prostate screening and got a bit of a lecture but no hysterics.Both of those cancers are common, cervical cancer is not.About 2 months ago I returned from a vacation with a rash on my face and some swelling. It was some sort of reaction to humidity. (my guess) I was very uncomfortable.To cut a long story short, the Dr refused to give me a script until I had a pap test, pelvic and breast exam. In the end he said he'd reluctantly settle for the pap test and "let me off" the rest of the exam this time.I won't be treated like that and left without my script.I went to the pharmacy and used an over the counter preparation that was not as good, but over about 3 weeks the condition improved.I should have seen another Dr but I'm afraid my negative feelings about doctors are stronger than ever.Do I have the right to demand treatment for my skin condition or can doctors demand unrelated exams at any consult?I've never heard of a man having this problem but it seems to happen now and then to women and we always get lots of pressure and hysterics about gyn exams.Thank you for your help.Kate J
Go to a dermatologist for the rash, Kate J. They should be able to help you and chances are good they won't put pressure on you in regards to having a pelvic exam.Did you question the doctor about why he felt that was necessary for a rash on your face? Also, don't be afraid to say, "Are you saying you refuse to treat my rash unless I submit to personal exams? I want to be clear." Put the pressure back on him.
Kate J,Going to a dermatologist is good advice to get your rash treated. You don't say whether you're seeing a family doc, internist or gynecologist for the rash. Certainly the first two docs are more likely not to bother you about a Pap. Many would rather not do them.But I don't think it is ethical for a doctor to withhold treatment for an active problem to force you to do screening, or anything else for that matter. And only women seem to be subjected to this kind of duress. It's not malpractice; doctors can withhold treatment if they want, at least in the US. But if he/she is not going to treat you, they should refer you to someone who will. It's a form of abandonment otherwise. You could file a complaint with the appropriate state board. Make sure you include some documentation that what the doctor was forcing you do to was unrelated to your complaint. The doctor would be notified of the complaint. Any disciplinary action is unlikely, but the physician would probably think twice before doing this again.
I can't imagine a Dr refusing to treat a skin problem until a patient agrees to gyn exams and a smear. Amazing!I don't doubt this happens in the States and probably elsewhere...I would definitely follow Dr Sherman's advice and see a dermatologist.I found this article:"Informed participation in cancer screening: The facts are changing,and GPs are going to feel it" in a Scandanavian medical journal.http://informahealthcare.com/doi/pdf/10.3109/02813431003625410The following points are made:There is a high spontaneous regression of dysplasia. More than half of women screened repeatedly for cervical cancer will be "captured" in a phase of dysplasia. (and remember this is probably assuming 3 or 5 yearly screening, it would be almost all women with annual and a higher % for 2 yearly screening)More than 50 will have to undergo conization for every cc death prevented. (presumably that figure goes up with more frequent testing schedules because they produce more abnormal smears & false positives)Breast screening - also high over-diagnosis and over-treatment.PSA testing - 47 men are overdiagnosed and treated for every man whose life is extended by screening.In a few countries, prostate screening can't be recommended because of it's over-detection & treatment of pseudo-disease and because men can be left with impotence and some incontinence.Yet cervical screening (which is uncommon) causes even more over-diagnosis and over-treatment, yet is basically accepted as a great screening test and any harms/damage dismissed as "minor".I can't accept that thinking and certainly not without express informed consent. Surely the only person who can say a damaged cervix or psychological distress is a "minor" consideration is the woman being offered the test.
I'm sorry that I forgot to sign my name. I recommended the dermatologist to Kate J. I hope she is able to make an appointment immediately so she can have the rash accessed. Don't let the actions of the other doctor prevent you or scare you from seeing another one that will be able to help. Dr. Lisa
Elizabeth's reference on screening is a good article on the pros and cons of screening. It is from a medical journal but quite understandable I believe to a lay person. I will add it to the woman's links.
Kate J again, thank you Dr Sherman and Dr Lisa for the advice.My rash has flared again and now I have one eye bright red and almost shut, a bit of new weeping on my neck and some itchiness. The OTC cream is not clearing it up, but improved things for a while. The pharmacist said I needed a cream only supplied with a script.The doctor is the family doctor I see now and then. He has pressured me about gyn exams and pap testing since I was a teenager and it appears he decided at that consult to make a stand and force the issue. I won't see that Dr again.I'll have to summon some courage and see a dermatologist, this problem has been going on for too long, is making me miserable and I look like a witch.I'll let you know how things go.Thank you once again.
How long are your consults?My Australian Dr is very busy and I always feel rushed in and out, she can't get rid of me fast enough with her waiting room bursting. She promptly deals with whatever my problem happens to be, she doesn't have the time to do an all-over check or pressure me to have all sorts of preventative care.She asks about pap smears every 2 or 3 years when you're on the Pill otherwise it's not even raised, it's up to you to raise it if you want one, as it should be. If you don't want a smear, she makes a note, briefly mentions the small risk of this cancer and the chance a smear "might" pick up something, takes your blood pressure, any other problems type Q and out the door.To have a debate with your Dr about all sorts of preventative things means the Dr must have lots of time on his/her hands. Sometimes I'd like to discuss something with my Dr but feel under such pressure, I cut it short and get out of there.Perhaps you need to find a busier Dr, I've never been hassled about anything not even my smoking.Paula
I was looking into the benefits of EGCG (from green tea, of course) and found an abstract about cervical dysplasia and EGCG. Apparently 69% of women with dysplasia given EGCG had an positive response versus 10% in the control group.This study came out in 2003 and I've never heard anything about it. If what this study found is true why would doctors jump to biopsies and other harmful treatments instead of giving women supplements? It's not invasive or harmful to at least try. Is it really all about money? It must be. Hundreds or thousands spent on biopsies and a few dollars spent on supplements ...
Sorry! forgot to post the link!http://www.ncbi.nlm.nih.gov/pubmed/14512803
Well anon, it's not quite so simple. Western medicine tends to be suspicious of Eastern medicine and herbal studies. The study quoted was small and needs confirmation in a much larger study which is expensive. Almost all research nowadays is funded by drug companies and they're not going to do it unless they can patent the drug and make some money off it. But it's hard to make money off green tea. These same fiscal restraints apply to the entire healthcare field, not just women's issues. Thirty forty years ago most research was government funded, but now very little is. Private industry will only study an issue if they see a chance of making a profit.
Dr Sherman I came across this story. Surely this is not true? http://www.alternet.org/reproductivejustice/147254/after_cutting_little_girls'_clitorises,_ivy_league_doctor_tests_handiwork_with_a_vibrator?page=1Nic
Nic,I went to the original article and it's not as bad as you think. The procedure was used on girls with congenital virilizing syndromes only, that is girls with abnormally large clitorides. That's a condition most women would want corrected. And it is important that the nerves be kept intact.I came across a different article that the CDC (Centers for Disease Control) recommended 4 years ago that HIV be routinely screened for in teenagers. Don't know anyone who does that. Seems like overkill to me.
I can hardly believe what this articles says! --- A committee opinion of the American College of Obstetricians and Gynecologists says adolescent girls may require two "well-child" visits annually -- one general preventive visit and one dedicated to reproductive health, and recommends that a girl's first reproductive health visit happen between ages 13 and 15.http://allnurses.com/clinical-news/panel-urges-two-487830.html
That is rather startling Anon. I will try to look at the original article in the journal.It is an incredibly self serving recommendation, that every teen age girl see a gynecologist annually even though no exam is needed. Are they trying to make up for the loss of annual Pap smears with their new guidelines?Obviously a family doctor or pediatrician could do any sexual counseling just as well.I'll comment further when I've read the article.
This is news to me. Apparently Gardasil increases the risk of cervical cancer if you have already been exposed to the high risk strains of HPV. No wonder they recommend giving the vaccine primarily to young tweens. This information does not seem to be widely known. It raises the question whether everyone should have an HPV DNA test before getting the vaccine. Of course the maker of the vaccines would be against that recommendation as it would mean requiring a pelvic exam for all these young girls and many would refuse.
For just about any other drug the FDA would have already pulled it off the shelves. Why is there so little inaction about Gardasil ?
Yes I am puzzled by the news that Gardasil increases the risk of cervical cancer in women who are seropositive for high risk strains. I would think that the vaccine should at least come with a black box warning that the HPV test should be negative before administering it. A black box warning is the strongest warning that can be included with prescribing information.
Two well child visits a year. How ridiculous! As the 15 year old poster over on over on the unecessary pap smear blog (who is being pressured by her mother to go to her gynecologist) said, why doesn't my brother need a yearly inspection of his genitals?!Nic
I have now had a chance to review the ACOG position paper stating that all girls between the ages of 13 to 15 should have their initial ob-gyn visit and then be seen annually. (Obstetrics and Gynecology Vol 116: #1 July 2010 p 240-243.) They give 2 references for their opinion, both also position statements of the ACOG.As I expected, these are totally opinion pieces that all girls would be benefited by seeing gynecologists from age 13-15 up even though they state they don't need pelvic exams or Paps yet. So the purpose of these visits ostensibly is just for counseling about sexual matters. They recommend that the physician meet with both parent and child together, then each separately, and then together again, a visit that could easily take an hour. They present absolutely no empiric data that any health outcomes would be benefited by these visits in the fashion that the USPSTF would present. Clearly though Ob-gyns would be benefited by having insured themselves more patients than they can ever handle. So my conclusion is the same, the recommendations are totally without any scientific merit and are unabashedly self serving.
Dr, in those early exams they make it sound like a general exam or a talk but they want to look closely at the genitals. My friends were put into stirrups for that part of the exam.They don't do a pelvic exam unless you need one and my friends were told they'd have their first pap at 18 or when they had sex, whichever happened first. The Dr checks the breasts as well to see they're normal.Two of my friends have had these exams. They went thinking it was a talk and came back crying.I think they say it's a talk to get girls to go but it's a lot more than that and very embarrassing. It's a shock when you're not expecting that too.I won't go and my friends are never going back. Word is spreading and lots of girls are refusing to go.Now doctors want even younger girls to go, at 13 or 14. Girls and parents should not follow this advice. Amy
Amy, the ACOG position paper (which I can't publish online) does state that an external examination of the genitals and a breast exam is appropriate for at least some visits. They do not mention stirrups.I can't imagine that there is a routine health benefit from any of this if the girl is asymptomatic. I'd also be surprised if the average gynecologist is a competent sexual counselor of adolescent girls. Probably most pediatricians are better or just as good. But I would think that most 13-15 year old girls would have a strongly negative reaction to these exams. We certainly did not submit our daughters to exams at that age.
Dr Sherman, Could this be a way of making up some of the business American gynaecologists fear they'll lose with the easing of pap smear requirements? I know they're still saying they want to see women yearly for pelvic and breast exams, but that must be sounding a little thin to some American women with the creeping awareness these exams are unnecessary and may be harmful.You seem to have a lot more gyn's than the UK or Australia, I suppose you'd need them with most women seeing them for routine gyn care their whole lives or using them as their primary physician...whereas we see a gyn when we're symptomatic, pregnant or have a gyn issue. (want an IUD)I was watching an American show on Foxtel with three female gyn's and one Dr said she loves caring for her patients their entire lives...at puberty, when they need birth control and routine gyn checks, when they have babies through to menopause and old age. It struck me how different it is in other countries. Few women would have a gyn overseeing their lives and if they did, poor things, it would probably be women with continuing and serious health issues like endometriosis. (but I doubt that contact would be life long)The article about Gardasil is a shock. Why wouldn't they tell women/girls about that risk? I can imagine some girls might not want their parents to know they're sexually active and have the injections only to increase the risk from cervical cancer.If they have issues later, I suppose they'd have evidentiary issues trying to lay the blame on Gardasil - causal link and all that. We really need to be our own advocates these days, but I do fear for women (and men) who are unable to protect themselves.
American doctors always seem to use stirrups, I've read they think it enables a better exam, no thought for the poor patient.They sound awful, I've thankfully never experienced stirrups.What would they do if they didn't use stirrups?They'd all have stirrups on their exam table, it seems the usual way women are examined in the States. Would the girl be examined on the exam table and be asked to bend her knees and let them fall apart? (which happens in many countries) Or, asked to stand for this visual inspection? I really find it hard to understand why any doctor would think it's necessary in a girl with no symptoms or health issues. Surely you'd do that exam when it's clinically necessary, not on every girl.These exams would be hard anyway it's done, but stirrups would be quite frightening for many girls/women and I guess some gyn's would use them whether they should or not.Just curious... Beth
Elizabeth, the recommendation for annual gyn visits for adolescents was made before the ACOG went on record that Pap smears can be done every 2-3 years in many circumstances. So they're not directly related, though the College must have seen it coming when they made the recommendation. But in any event, they still I believe recommend annual pelvic exams whether or not a Pap is indicated. Clearly though the College is well aware of the effect their recommendations have on the number of patients they will see, so I don't think you can separate them.Elizabeth, American medicine has been oriented towards specialty care for the last 30 years or more. We have fewer general practitioners percentage wise than any other country I know of. Some younger women do use gynecologists as their only physician, though I don't think anyone recommends that. In the USA I believe all pelvic exams are routinely done in stirrups. I really don't know why.
"So my conclusion is the same, the recommendations are totally without any scientific merit and are unabashedly self serving."I concur.....
Really doctors are the same as lots of other groups. I had a car salesman trying to tell me I should trade-in my car every year rather than risk depreciation and breakdowns. Of course, there is no reason for it and financially it would be a disaster, but wouldn't it be great if he could persuade even a small % of the population that they should follow his advice.Now doctors come from a position of trust and are more likely to be believed and followed (by some anyway)...yet it sounds like most of these recommendations are no more than business and marketing plans and not in the patients interests at all.I started to doubt my doctor when he recommended a cat scan for back soreness and then again for neck soreness. I said I'd prefer to wait, I'd been to Cambodia and spent several days climbing up stairs at the temples and thought with time my soreness would ease and it did.I then read that doctors were over-prescribing cat scans and risking their patient's health.I'm more cautious now. Kasey
Here's an article about a fairly prominent US pathologist who has written about the risks of cervical cancer screening and who warns that indeed Gardasil does increase the risk of cervical cancer in girls/women who have already been exposed to the high risk genotypes of HPV.
Interesting article but they always fall back on the pap smear.Who worries about very small risks?The fuss over something that would affect 1%-1.5% of women with no screening at all is hard to understand. It's like someone forgot to tell these doctors to move on to something more important, a major threat to life like lung cancer or heart disease.I'm sick to death of hearing about cervical cancer. If there were no screening, we'd never hear about it. Who talks and worries about other uncommon cancers?Sienna
Today my local newspaper ran an article in the woman's pages (which my wife noticed) giving the new recommendations of the ACOG that girls from 13 on should have two routine physician visits a year, one with their family doc and the other with their new gynecologist. There was no commentary or discussion. They just paraphrased the original article.It's really disconcerting to me that these opinions are publicized as if they were accepted facts. If you come across articles like this, you should challenge them when feasible.
This is like finding out the tooth fairy is actually a parent.I posted over at blogcritics, I had intended to give them a blast. What sort of nut criticizes pap tests?I myself had life-saving treatment after an abnormal pap smear when I was 23, didn't I?Ummm, no, it turns out I didn't. I was led to believe I'd been saved by this test, but I actually had a false positive. The biopsy was normal even though my pap was slightly abnormal.My Dr had 3 days to get me an answer and I was told clearly this time I didn't have cancer and wouldn't get cancer in the future as a result of the abnormal pap, it was an error, the pap said I had a problem, when I was perfectly normal.It don't know why my Dr didn't make that clear until I actually asked, was it a false positive? I wouldn't have known to ask that question when I had the treatment.I got no information that I can remember, it was painted in a different light."lots of women your age get abnormal smears and need lesions treated before they go further"(most don't develop into cancer)"HPV is everywhere and causes cancer, it's very important all young women have yearly paps". (HPV only causes cancer in a small number of women)I can't say those statements are lies but they stop well sort of informing me.At least I was able to get some information here. The summary is very helpful.Thank you Dr Sherman for taking the time with this website. This is really the only place women can easily get their hands on this information.Josie
I caught the tail end of a report on this morning's "Good Morning America" in which anchor Robin Roberts and GMA's medical consultant, Dr. Richard Besser, were discussing annual physicals and which screening tests were needed for men and women. Dr. Besser was dicussing prostate cancer screening and said it's something men should discuss with their doctors. He said he discussed it with his personal physician and decided screening was not warranted in his case. Funny how we women are never encouraged to discuss pap smears/pelvic exams with our physicians or are given any choice in the matter.The report made me so angry, especially considering prostate cancer is many, many times more common than cervical cancer. I then went to the ABC News site and found the checklists associated with this report. For women, it says to have a pap smear every 1-3 years, but those women who are 65-plus and have had several negative prior paps don't need to. Nothing optional about the pap, but something women should have done.On the men's checklist of "musts," prostate screening isn't even listed. There is a small section underneath the checklist that says men may wish to discuss other screening options such as those for glaucoma, prostate cancer, etc., but prostate screening is not presented as a must-have test. I just don't understand why we women are almost ordered to have a test for an uncommon disease, yet men are encouraged to discuss and make their own decisions regarding screening for a much more common one.Susanne
Geena here...I don't want pap tests and my doctor said if I feel that way, I should think about a hysterectomy.I think it was said to shock or scare me.I have heard of very high risk women having their breasts removed to avoid breast cancer, but never heard of having a hysterectomy to avoid cervical cancer.Has anyone else heard this advice?I'm not high risk, two sexual partners (the first BF was a virgin, so was I, and the second had one previous long term GF)always use condoms (I can't get BCP's without pap tests)and don't smoke.I'm not following this advice, but it has upset me.
Geena, I certainly have never heard of recommending a hysterectomy merely because you don't want Pap smears. Even if you are relatively high risk it seems outrageous.Susanne, I can't explain the huge difference between how cervical cancer screening is treated and nearly every other cancer. Pap smears were started in a different medical era when screening wasn't looked at critically. Pap smears did reduce the incidence of cancer, and the downsides of screening have never been generally acknowledged.
Here's an example of the kind of worthless information which floats around women's magazines and blogs about cervical cancer.It includes the gem that there may be millions of cases worldwide of cervical cancer, probably off by a factor of hundreds.
Dr Sherman that website is obviously an unreliable website with bad English etc. I think most women would not take it too seriously. However, this website http://www.healthblurbs.com/cervical-cancer-why-pap-smear-is-a-little-inconvenience-life-saver/supposedly written by doctors is more of a concern.Nic
Dr Sherman,Are you concerned about the number of women having hysterectomies after abnormal pap tests?My 26 year old friend had a hysterectomy last month after two abnormal pap smears. She doesn't need any further treatment and the pathology was "benign".She is part of a support group for young women affected by cervical cancer but I'm not sure they have been affected by cervical cancer. Does an abnormal pap test mean cervical cancer? My reading here says definitely not. Women seem to be acting under the notion that an abnormal pap is cancer and means a hysterectomy is warranted.I'm a bit concerned about this situation which is very common. I have no idea how common, but at one meeting, my friend met 8 women under 30 who all had hysterectomies after abnormal pap tests.I'm not sure what's happening and this is the first place that seems to have identified a problem with the current testing and advice being given to women.
Belle,Yes, the US has a very high incidence of hysterectomies, much more than other countries. Not all of them by any means are done for abnormal Paps.I'm not an expert on the field. Read through the women's links for more information. But my reading would be that hysterectomies are rarely warranted for abnormal Paps, only for invasive cancers. Even the highest grade abnormal Pap smears would generally be treated with cone biopsy or LEEP, especially in young women who might still want to become pregnant.
Belle, I am extremely concerned about this. How does your friend feel now that it wasn't cancer. I would be seeing my laywers if that was me. Another good blog is http://blogcritics.org/culture/article/unnecessary-pap-smears/comments-page-22/#commentsYou might find that there is more pertinent information at the end of the blog.Also go to this site too. http://medicalconsumers.org/tag/screening/It mentions unnecessary hysterectomies after abnormal paps.Nic
Thanks for your comments.I plan to do more research. Something scary appears to be going on and most women are oblivious to it. How can a hysterectomy be necessary when the pathology is benign? Wasn't cancer found before the operation? Did the lab mess up? I have many questions. My friend is getting counseling and support from a group of cancer survivors. It seems crazy to me because she never HAD cancer! It wasn't a scare, it's not a question of them getting it all, she never had it!That point is missed in all of this, these women think the operation has saved their life.I want to get more facts together before I raise the topic with her. I'm not making light of her situation or being unsympathetic, but it doesn't add up.
Here's a link talking about the hidden risks of giving your children Gardasil with emphasis on the increased risk of cervical cancer if there has been prior exposure to HPV.
Belle please keep us posted. I want to know what happens when the penny drops for your friend. This seems to be the tip of the iceberg. I never heard a more unscientific diagnosis than precancer. I cannot believe that many of these women are giving up their chance of motherhood over nothing!Nic
For whatever reason, this comment by Anon wouldn't publish directly:Dr. Sherman,I was reading the article from the ACOG that you posted. In the first paragraph they say in the 1970s CC affected 14.8 out of 100,000 women and in 2006 it affected 6.5 per 100,000 women.If that's true it means 0.0148% of women got CC in the 70s and 0.0065% in 2006. Those numbers are so tiny it sickens me.And except for a few differences the recommendations are to basically treat all women the same when it come to testing.There's no mention of informed consent and it hardly address the risks associated with false positives.It's a disgusting article which doesn't address any of the dangers of screening. And did it even occur to the people who wrote this that cancer screening is optional and some women may not want to screen?I know that for a very few women this screening has helped, but for the vast majority of us it hasn't helped, or worse, done more harm. It is very sad to see the medical community have this view of all women must test for CC.I'm from the US and the only time I was told I didn't have to screen was followed by a, " but I knew a 21 year old who died of CC in six months."No matter how many articles come out they will never be able to teach honesty and respect towards women.Posted by Anonymous to Medical Privacy, A Patient Oriented Discussion at April 24, 2010 4:11 PM Here's a reference to a minor update from the ACOG listing their exceptions to the age recommendation of 21 for women to start Paps. Basically it includes high risk immunologically impaired women.
Anon,I'm no longer sure which ACOG article you're referring to; there have been many.But the statistics you quote are likely for a given year. A more significant measure of risk is your lifetime risk of getting cervical cancer which for most women is near 1%. That's still small, but not minuscule. But I certainly agree with your other comments.
If you don't use a doctor for birth control, they can't blackmail you.I was angry when I worked out none of the things they demand are actually necessary, they are not done overseas and cause lots of bad outcomes. Routine pelvic and breast exams are not recommended elsewhere and having them carries risk. My 26 year old friend had a healthy ovary removed after the Dr said there was swelling (she was forced to have the pelvic exam to get BC)If you look at all these diagnostic tests and surgeries, many are completely unnecessary and caused by these exams. It's drumming up business.If you can't stand up to doctors, don't use them for BC and you can then make your own mind up about screening.It appears the evidence for routine pelvic and breast exams is not there, all I found was risk and not much benefit.Paps have been elevated to a position they don't deserve, we all need to claim back our rights, demand risk information and an accurate assessment of the test and make up our own minds. The current practise where doctors make decisions for us, decisions that are often unwise and hurt us, must be stopped.Carmen
Hi Carmen, I agree with you 100%Dr Sherman, Hexanchus posted this link to the blogcritics site and I wondered what you make of it.Shouldn't this be referred straight to the authorities?http://www.thehastingscenter.org/Bioethicsforum/Post.aspx?id=4730&blogid=140Beth
Something I caught onto...the number of young women who've had treatment. I have a few friends who all had treatment before 26 and all are pap smear obsessed...it saved my life, I've had a scare already stuff.Not one saw any pathology, the doctors report to them was vague. Given these are the very women least likely to get any benefit from smears and most likely to have false positives, always ask for your pathology.Also, don't agree to LEEP, LLETZ or a cone unless you've had a pinch biopsy. This option is rarely given to young women even though the chance it's cancer or pre-cancer is 1 or 2 in a million and the chance it's a false positive, almost a certainty.If the biopsy comes back clear, walk away!Do your reading and make the next test your decision.I think doctors favour LEEP because it leaves no pathology and they can easily get away with these procedures saying it was "possible" there was a real problem.When these procedures cause major problems and they are really unpleasant things, they should be done sparingly and as a last resort. Personally I think screening before you're 30 is like dashing out in front of traffic...really silly and dangerous. These women are blindfolded as well, because they haven't been told the most important facts and haven't really consented at all.I can see why a high risk woman might have a smear every 5 years from 30 or even 35 and I wouldn't test past age 50 or 55 if they were all normal (incl false positives which means normal!)I can't accept that the way this screening is framed has much to do with preserving our health, the harms are happily accepted by doctors and women are oblivious to them.As it stands it's a very harmful and illegal program.Megan
Beth, I'm not sure what to make of your reference. I believe I commented on this before after reading that the patients described here had a congenital masculinizing syndrome and pathologically enlarged clitorides. That's a condition no woman would want, and surgical correction seems reasonable. Obviously the resulting sensitivity of the clitoris would be important to the girl so the concern is valid. But I can't clinically comment about how appropriate or ethical their testing procedure is without knowing a lot more about it. You need some kind of testing to evaluate a new procedure.THIS THREAD IS NOW FULL. PLEASE CONTINUE POSTING ON PART 6.
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