Is family physician really enough?

DEAR DOCTOR » I’m a 76-yearold woman who had a complete hysterectomy when I was 50. My daughters insist that I should still be seeing a gynecologist for cervical cancer screenings, including pelvic exams. Is this really necessary? I already see my family physician every six months for a checkup and blood work.

DEAR READER » Your daughters’ confidence in this screening is understandable. Pap smears are an important part of primary care medicine, proven to decrease the rates of cervical cancer and related deaths. Years ago, physicians recommended annual Pap smears for every woman over the age of 21. Now, with the knowledge that cervical cancer is directly linked to HPV infection, doctors understand that screening intervals for Pap smears no longer have to be yearly. The U.S. Preventive Services Task Force now recommends Pap smears every three years for women ages 21 to 30, and both Pap smears and HPV tests every five years for those ages 30 to 65. These recommendations include shorter intervals if the Pap smear shows abnormalities or if the HPV test is positive.

Women who haven’t had an abnormal Pap smear and whose HPV tests have been negative have a very low risk of developing cervical cancer after the age of 65. One reason for this is the low likelihood of acquiring a new HPV infection past that age. Many doctors — including myself — don’t normally recommend Pap smears for women over age 65.

Women who have had a total hysterectomy, in which the cervix is removed, are even less likely to need a Pap smear. Some hysterectomies remove the uterus and leave the cervix, but that would have been highly unlikely 26 years ago. For that reason, I’m assuming that your cervix was removed. If so, you cannot develop a new cervical cancer. If your cervix showed cervical cancer before it was removed, then a Pap smear is reasonable to assess whether the cancer may have returned.

True, other cancers can sometimes be found on a pelvic exam, such as ovarian cancers, uterine and vaginal cancers, but not very reliably — meaning pelvic exams yield little benefit. For instance, although the only good screening test for vaginal cancer is a visual exam of the area, because the incidence is low (1 in 100,000 women), the yield for screening is also low. Ovarian cancer is much more common, but has no good screening tests. A pelvic exam can sometimes detect an ovarian cancer, but not easily; the tumors are generally small and the ovaries’ location makes finding them difficult. As for uterine cancers, they’re typically found when a woman notes abnormal bleeding from the uterus.

When I started medical school, many physicians did yearly Pap smears and pelvic exams on women over age 65. As the science became clearer, the medical community has altered its thinking. Although some physicians still recommend yearly Pap smears and pelvic exams regardless of a woman’s age, the practice is becoming increasingly less prevalent.

Unless you have one of the signs of cancer in the pelvic region, such as vaginal/uterine bleeding, abdominal bloating or pain or vaginal pain, you’re correct: There’s little use for a routine pelvic exam. Robert Ashley, M.D., is an internist and assistant professor of medicine at the University of California, Los Angeles. Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o Media Relations, UCLA Health, 924 Westwood Blvd., Suite 350, Los Angeles, CA, 90095.