Women’s health visits are constantly changing and improving, making what your mother or her mothers routine check ups vastly different…
The estimated doubling time of total medical knowledge in 1950 was 50 years; by 1980, it was 7 years. In 2020, it was estimated to be just 73 days. Soon, what is known about medicine is projected to double every 12 hours. The internet has made global collaboration across borders, cultures, and languages possible, and no area of science has benefited more than medicine. This also means that there is just so much more to know.
WOMEN’S HEALTH—TWICE THE SPECIALTY—IS EXPANDING FASTER THAN THE OTHERS
Women’s health comprises obstetrics (pregnancy) and gynecology (everything else before and after pregnancy). Along with the inevitable subspecializations emerging in other specialties, OB/GYN has branched out into primary care, endocrinology, fetal surgery, and more. In essence, the “OB” and the “GYN” are two specialties, each growing at least as fast as others in medicine, creating a double, parallel growth.
Consider how many doublings in medical knowledge will occur during the 7 or more years of medical school and residency a physician experiences. However, while the internet is flooding us with information, it is also aiding us in processing that information. Many advancements are smaller points within major areas of knowledge—and the internet collates these changes in real time. Thus, it is now possible to have health care that is both current and organized. You should know that it is not what your mother or grandmother had.
THE SAME STEAK
About 20 years ago, as women’s health care was just entering the computer age, a steak cost about $35. Today, the costs of both have risen, and while you’re still getting the same steak, you’re not getting the same health care.
Today, steak is still rare, medium, or well done; but women’s health care has added BRCA mutation testing, genetic HPV testing, and 3-D ultrasound-guided needle biopsies. Of course, this is an incomplete list. Aside from obstetrics, what has changed in women’s health care gynecologically?
THE SCIENCE OF PREVENTATIVE CARE
Women’s health care is a science of prevention. We have extended the human lifespan through advances in detecting and meeting cancer and infectious disease head-on. On another page—in the same book—we have lengthened a woman’s projected lifespan by mitigating the morbidity and mortality of breast, ovarian, uterine, cervical, and other cancers.
Current knowledge is continually changing on how we screen for these. Although a woman’s complex physiology dovetails with her hormonal system as a unified, holistic entity, the most efficient way to watch for these cancers is still to monitor the individual areas of concern:
The risk of breast cancer averages about 12-13% in a woman’s lifetime. However, breast cancer deaths have declined by 40% in one generation due to improvements in early detection. Women at average risk for breast cancer should be offered the following:
- Screening mammograms at age 40 (but no later than 50), then repeated every 1-2 years until age 75, when discontinuing them is an option
- A clinical breast exam every 1-3 years for ages 25-39 and yearly beginning at 40
- Decisions on the timing of the initial screening mammogram and repeats are a shared decision between a woman and her physician
The risk of breast cancer in women with a BRCA mutation is 45-85% by age 70. A woman with a family history of non-breast cancer (e.g., ovary, uterus, colorectal) may still be at high risk for breast cancer unless BRCA mutations are ruled out. This is because a family’s BRCA mutation increases the risk of all these cancers for all family members affected.
OVARIAN CANCER SURVEILLANCE
Ovarian cancer risk increases with age, especially after menopause. Since the screening blood tests (primarily the CA-125) for ovarian cancer may be unreliable, the best chance to catch it early is with a routine pelvic exam. When symptoms warrant or the exam is worrisome, an ultrasound can be done.
UTERINE CANCER SURVEILLANCE
Most cancers of the uterus are from its endometrial (innermost) lining. Although its incidence rises with age, endometrial cancer is more frequently diagnosed after menopause when it isn’t normal to have vaginal bleeding, and endometrial cancer bleeds. This tip-off will prompt an ultrasound and a sampling of the endometrium, done via a vaginal approach.
Otherwise, screening involves taking the usual history (e.g., bleeding, pain, weight loss) and performing a physical exam during regular patient visits.
CERVICAL CANCER SURVEILLANCE
Few screening protocols have changed as drastically as those for cervical cancer. The cervix is part of the uterus, but its tissue is different, so its cancer is like that of an entirely different organ.
The story of detecting cervical cancer includes this timeline:
- 1947: Dr. Papanicolau developed a microscopic evaluation of cells scraped from the cervix (the “Pap” smear) to identify any that are abnormal. This has reduced cervical cancer incidence by 70%. Since that time, variations in preparation and computerization have greatly improved the Pap smear’s speed and accuracy.
- 1970s: use of the colposcope (a microscope used to closely examine the cervix) became the standard of care in the USA for abnormal Pap smears.
- 1980s: the link between human papillomavirus (HPV) and cervical cancer was made.
- 2006: the HPV vaccine, Gardasil, was introduced to prevent the cause of cervical cancer—HPV infection.
- 2012: the US Preventive Services Task Force updated the cervical cancer screening protocol.
- 2018: due to the slow progress of HPV infections, evidence-based medicine has allowed the timing of screening and follow-up to be relaxed. The current recommendations include the following:
- Under 21: no screening needed (Screening was formerly begun once sexual activity began.)
- 21-29: begins at age 21, with a repeat Pap smear every 3 years
- Age 30 and over with average risk: a Pap smear every 3 years or HPV testing without a Pap every 5 years
- After 65 or for those with a prior hysterectomy: no screening if there’s been a negative screening history
- For those with positive screening for HPV, colposcopy is used to determine the timing for a recheck or if treatment is indicated
Cancer isn’t the only killer out there. A hip fracture can also kill by creating a setting conducive to blood clots. Women can expect to live roughly a third of their lives in menopause when the loss of estrogen raises the risk of bone resorption, stratified clinically as either low bone mass (osteopenia) or severe bone loss (osteoporosis).
Diabetes is also a target, as well as skin cancer, mental health issues, and heart disease. Even though female-associated conditions are important, the other human problems need to be identified and addressed. This brings a more primary care focus to the practice of obstetrics and gynecology.
Colorectal health is another important area for prevention. Screening for colorectal cancer begins in men and women at age 45.
The internet is advancing medicine like never before, but it is also parsing all of the data for prioritizing ways to benefit women with the most efficient strategies. The only unchanging thing about medical guidelines is that they will forever be changing. Such change is good for everyone because it is not merely adding to the current medical knowledge but maturing it.