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Wednesday, May 13, 2009

Women's Privacy & Modesty Concerns

All comments on women's issues are welcome here. The majority of this thread has concerned the usefulness of cervical cancer screening. I think most of us have learned some surprising facts about cervical cancer.
This thread is now full and will not accept further posts. Please continue posting on Part 2.

198 comments:

Joel Sherman said...

I'll post more here as I can. Ladies, please post your concerns or stories.

Pamela said...

A few years ago I had something happen. I had to go to the ER, as I was having a tachycardia episode and I couldn't get my heart to slow down by myself. The ER staff whisked me away quickly and set to work helping me. Before I knew it, my heart was beating normally again. After it was all over, though, is when my privacy was violated. (or at least, I think it was!) There was a guy in my "room" who I think was a nurse, although he might not have been. I don't know. He was there the whole time they were working on me, so I figured he must be a nurse or student of some sort? Anyway, I had those stickers from the EKG on me, and he came over to remove them. I told him I could do it myself. He told me no,it was okay, he'd do it for me. Before I knew it, he whipped my gown up and began peeling them off of me. The curtain wasn't closed or anything, and I was in full view of the whole back of the ER. I don't really remember if anyone was outside the room to have seen me or anything. It was just a bit embarrassing to have him do that. I was more than capable of removing them myself, as I've had many, many EKG's before. I think when I told him no, I'd do it and held my gown down, that should have been it. He could have at least closed the curtain. And I also know from experience that those stickers CAN be removed discretely. Anyway, maybe that wouldn't be a big deal to happen to someone, but it was for me. I'm a very modest young woman. (and of course, even younger then) Perhaps these doctors and nurses and other medical professionals see people's bodies all the time and it's no big deal to them. But it IS a big deal I think when it's your own body on display for all to see. Anyway, that's my contribution!
May 1, 2008 10:30 PM

Joel Sherman said...

Sam said...

Informed consent has always been ignored with cervical cancer screening.
Doctors in the UK & Australia are paid to reach screening targets which has caused some very unethical conduct. (particularly in the UK)
I believe screening targets are in direct conflict with a doctors obligation to obtain informed consent.
In the UK the situation reached serious levels...doctors pressuring, harassing, coercing, frightening, intimidating - two doctors pressuring one patient, women being asked to leave a practice unless she agreed to testing, being labeled defaulters and refusers, opportunistic screening...so women couldn't see a Dr for a cold without being pressured...doctors asking women to sign disclaimers.
Also, totally inappropriate testing is a problem around the world - testing virgins & pushing women who've had complete hysterectomies for non-cancerous conditions into testing.
Thousands of women are being forced into testing and/or being tested unnecessarily...and we're talking about a VERY invasive exam.
It was also fairly common for doctors to refuse the Pill without testing - cancer screening has nothing to do with contraception - I doubt any of our doctors do that now - women are more aware.
In the States however, severe medical barriers prevent access to the Pill. (pelvic, rectal and breast exams and annual screening)
My US colleagues receive their medical care in HK and avoid US doctors - they regard these requirements as totally unnecessary and therefore, unethical and even abusive. Informed consent is once again, totally disregarded...even though many US medical associations (follow the rest of the world) and say these requirements are unnecessary, the doctors still persist with their requirements preventing access.

The UK General Medical Council have finally made a stand...
Dr's must now disclose they have a conflict of interest, admit the woman has a low chance of benefiting from the testing (uncommon cancer) and a fairly high chance of an incorrect test result and that a false positive leads to biopsies which can be harmful. (unreliable test)
The Dr MUST obtain informed consent and respect and accept the woman's decision.
A Dr can offer a test, but that's all - they can't recommend or anything else.

The truth behind this test is eye-opening - Dr Angela Raffles (UK cancer screening expert)released some statistics - 1000 women need regular testing for 35 years to save ONE woman from cervical cancer.
Armed with the facts, ALL of them, (and considering your risk profile) many women may choose not to have testing or have it less often...
Until recently, it was impossible to make an informed decision - women were given misleading information and no risk information - a scare campaign was used to force compliance.

Smoking cigarettes is a FAR, FAR greater risk factor for cancer than choosing not to have an unreliable test for an uncommon cancer - a test more likely to harm you, than help you.

A report by RM DeMay published in 2000 in the American Jnl of Clinical Pathology, "Should we abandon pap smear testing" says that of the 1% of women who'll get this cancer, ONE THIRD will have a false negative test result and may delay seeing a Dr for symptoms, reassured by the test result and therefore, face a later diagnosis - so this group may be disadvantaged by testing...that leaves 0.66% of women to benefit from screening.
Apply your risk profile and your chance of benefit may be tiny.

The other fact - two yearly testing means almost 78% of women will have biopsies, with only a very small number having any sign of cancer - annual screening means 95% will have biopsies - three yearly 65% (L.Koutsky, Cancer Prevention, Fall 2004, Issue 4 & DeMay Article)
A false positive causes enormous anxiety and biopsies are very unpleasant and painful - some women take weeks or months to heal and some are left with permanent damage that can cause problems with fertility and during pregnancy.
I'm grateful I was alerted to the real facts 30 years ago...and now I see the same deception with breast screening.
I would never agree to mammograms - yet most women have no idea of the significant risks.
The Nordic Cochrane Institute have just announced that the breast screening brochures should be redrafted because they don't provide risk information - just the upside of screening.
How disrespectful to women and how arrogant - to take chances with our health by keeping us ignorant, afraid and deliberately misleading us?
When did medicine become so dishonest?
Cancer screening is offered to healthy people - IMO doctors are morally and ethically obliged to present all the facts and leave the decision to the patient.
We are all prepared to accept different types and levels of risk in our life.
Informed consent - don't ask a Dr - most have never heard of it or consider themselves above it...
May 12, 2009 11:23 PM

Anonymous said...

Pamela, for what its worth I think you have every reason to be upset. Regardless of the motivation whether it be some sort of malicous purpose or just insenstive, the patient should have complete say over their body especially when there is no negative medical ramifications. Even if they feel they have done this all the time...so what, that has nothing to do with how you feel, you are the patient, you have the right to say no. Sounds like it was a while back, but I hope you will read this and Dr. Bernstein's blog and realize you are not alone and feel comfortable insisting they listen to you.
Sam, after reading the extensive posts on these two sites, I have my eyes opened. I always assumed there was some reason pelvic exams were required to get birth control. I assume that there may be a side effect associated with the use of the pill(s) that put the woman, and there for the doctor at risk. It seems the concensous is the two are unrelated, that pelvic exams are just a screening exam totally unrelated to birth control which in my mind makes requiring them to get birth control extortion....that is not only wrong it is unethical....if that truely is the case, I hope someone sue's to get that taken care of....if there is no threat that a patient could have complications from the pill that the exam could catch and prevent...there is no way a doctor should be able to withold them unless they are performed....good luck with that..like I posted earlier, how can we as a society can consider passing a law that says doctors can not refuse to perform an abortion....but they can refuse to give birth control over some unrelated reason...what the heck is that about....alan

Joel Sherman said...

Here's an on topic article from a feminist blog on the medical establishment's treatment of indigenous women.
Abuses include unknowing sterilization without informed consent and lack of access to routinely recommended tests such as mammograms.
I already commented elsewhere on Pamela's post that the points raised have merit and I too find them eye opening. I refrain from giving an opinion on the medical facts because it is outside my area of competence.

Hexanchus said...

Pamela,

When the care giver proceeded after you clearly said no, he did more than violate your privacy, he committed a crime (assault and/or battery depending on the specific laws in your state).

Hexanchus

Joel Sherman said...

I am copying this post here from the informed consent thread as it is appropriate to both.

KN has left a new comment on your post "Informed Consent":

Sam is right.
I was pressured to have routine gyn exams from age 18 and always refused. I didn't need birth control so couldn't be forced.
I lived with fear and worry...every twinge was cancer.
I'm on an exchange scheme and currently living in Amsterdam.
I was surprised to find they don't recommend routine gyn exams AT ALL here and cervical screening isn't even offered until you're 30 and then only every 5 years. Virgins are not offered screening at any age.
I was SO relieved and happy and also very angry that our doctors treat us so badly.
I don't go to doctors at home because these horrible exams always dominate the consult.

I was brave enough to see a Dr recently for bad headaches after finding out Dutch women are not pressured or forced into stirrups at every consult or at all.
I felt comfortable with a doctor for the first time.
I asked the Doctor about this screening and she said, "it's not a perfect test by any means and cervical cancer is not a common cancer...I'll give you some information and the risk factors when you hit 30 and you can make your own decision whether you'd like to have the Test"...
I was shocked...MY decision.
A Dr speaking honestly and giving me a choice.
I asked whether birth control is withheld if you don't have the test. She looked surprised and said, "Of course not"...
In the States that always happens...no exams and test (including pelvic, breast and often a rectal plus pap smears every year) then no birth control.
Many of my friends manage with condoms rather than go through all of that. No wonder we have so many unplanned pregnancies.
Why are our health care systems so different?
I read on another forum that in this country womanhood is treated like a disease and we're all just a collection of our reproductive organs....that's certainly the way many of us feel.
I'm pleased that I'm away from all that and upon my return, I'll be armed with facts. I know our lives don't have to be dominated by these horrible exams and tests.
Hopefully, I'll be able to find a doctor who'll respect my wishes and still treat me for asthma, a sprain and give me birth control without insisting on all the invasive exams and tests.
It seems like a ridiculous thing, but it happens every day to thousands of women in our country.
My friend was denied antibiotics until she agreed to a pelvic and pap - she refused and made a fuss and eventually got her script. Women need to do more of that...stand up to our abusers.
I think it's sad that so many of us regard doctors as abusers.
Your Dr is supposed to work with you, not take advantage of you.

Joel Sherman said...

Apparently guidelines for routine pap smears have loosened in this country and now every two years is considered adequate in many instances. It's not my field but I would doubt that there is a compelling reason for a pelvic exam more frequently than that. Of course, a routine exam is likely the only way that uterine or ovarian cancer can potentially be picked up early, but that risk is obviously acceptable to some women. I don't know whether a pelvic exam is truly needed to start hormonal therapy, but it is apparently controversial.
I'd think it would be possible to find a physician willing to prescribe bc pills without an exam. Might help if you brought along the pertinent literature.
I think the reason physicians are reluctant to accede is in case there are problems, it would be harder to defend in case of a lawsuit.

Joel Sherman said...

I have again copied this from the 'informed consent' thread.

Sam has left a new comment on your post "Informed Consent":

Pap smears every two years means almost 78% of women will endure the ordeal of biopsies in her lifetime - it should therefore be each woman's choice whether she puts her hand up for that gamble.
(L. Koutsky, Cancer prevention, Fall 2004, Issue 4)
That's why informed consent is vitally important when you're pushing healthy people into cancer screening.
A few doctors in the UK have been very outspoken about the dangers and real value of screening. This is a brave act as the vested interests in screening run deep...it's a rich source of income.
Professor Michael Baum, a very senior UK breast cancer surgeon has been very outspoken.
He helped set up the fist breast screen centres and now believes they're doing more harm than good. He strongly disapproves of the misleading and incomplete information given to women.
To give you one example - in the UK, there was a scare campaign started by Breast Screen, "One in 9 women will get breast cancer, have your mammogram today!"....
I wondered about this 1 in 9 and went further...
This figure is based on the assumption that women will live into their mid 90's...in fact, most of us are gone by 82...if you adjust the figure, it comes down to one in 65....
Why is there so much dishonesty with screening?
I believe it's because doctors are rewarded for any drop in the death rate and are not penalized for the thousands of patients harmed in the process. Keep us ignorant and afraid and hopefully, compliant.
Informed consent and patient bodily privacy gets in the way.

Routine pelvic exams should also be the woman's choice - they are NOT recommended or carried out in other developed countries. How can they be vitally important to US women when they're not recommended or carried out in other developed countries?

If we choose to accept the small chance (even for high risk women) of this uncommon cancer and not risk an invasive and unreliable test, if we choose to accept a fairly high chance of disease through smoking or risk of injury doing adventure sport - that's our choice.
BTW the HOPE program at Planned Parenthood (US)now makes it possible to access birth control pills without an exam (apart from a history and blood pressure check)
They see that women are using less reliable methods and risking pregnancy, rather than giving in to medical barriers. It is also IMO, an acknowledgement that the risks of pregnancy are far greater than the risk associated with choosing not to have these exams.
I spoke to a senior Australian gynecologist recently at a staff dinner and he said that routine pelvic exams are of low clinical value and performed routinely usually cause more harm, than good.
If you look at the US, their women have more pelvic exams and pap smears than any other women in the world. Many more during pregnancy, required for birth control (except the HOPE scheme) required for HRT, recommended annually from your late teens.

I saw a chart recently that showed US women have more than 50-55 smears on average over their lifetimes - the country with the lowest rates of cervical cancer also, has the lowest rates of biopsies. (55%) Finland.
They don't screen women before 30 (young women have a high chance of false positives and extremely low risk for cancer) and then only every 5 years until 50, 55 or 60 (depending on risk profile)...5 to 7 tests in total.

US women need to ask themselves why all of this is being done - is it really about women's health?
In other countries, pelvic exams are only carried out on symptomatic women.
If you google routine pelvic exams there is a great article by Heather Dixon.
KN, go to Planned Parenthood upon your return and use the HOPE program. No exams or tests - I've heard they do pressure you after a while to have these exams, but that hasn't happened to any of my friends. If it did, they have their references to hand.
I agree Dr, that's the answer - we must be informed and protect our own health.

Sam said...

Alan, cancer screening and birth control are totally different things.

Informed consent is required for pap smears...yet many women don't get their Pills UNLESS they agree...
In my opinion, this is coercion and should be tackled in the courts.
Even if a Dr doesn't insist on it, it still relies on women knowing their rights and sadly, few do...so many doctors still pressure women presenting for the Pill. It's viewed as a good opportunity to screen.

When this screening was introduced, an unreliable test for an uncommon cancer - they KNEW they'd have to get as many women on board to show a decrease in death rates from this cancer and justify the millions spent on screening.
They KNEW this would mean sending thousands of healthy women in for biopsies.
I've spoken to many women over the years who've been through the trauma of biopsies - a highly invasive procedure and in the early days there were no or few female doctors...pain, humiliation, anxiety, worry, fear, bleeding and discomfort after the biopsy for days or weeks and some ended up with permanent damage to the cervix...causing infertility and problems during pregnancy....some gave birth pre-term and a couple needed to have cervical stitching to maintain the pregnancy.
This is highly unpleasant stuff...
Doctors did this to HEALTHY women without their informed consent. They decided not to tell us about the risks and to find ways to force us into screening....
IMO THAT is just disgraceful.

That is why I strongly disapprove of this Test being forced on women and doctors totally ignoring the need for informed consent.
Women should be given ALL the information and the decision left with them. No pressure, no lies or misleading information, no scare campaigns, no screening targets. We're not targets, we're healthy women.

The strategies adopted to "increase coverage" included opportunistic screening, (hassling women when they go to the Dr for anything) making it a prerequisite to get the Pill, paying doctors (well)to reach high screening targets (UK and Australia)...this is why we see virgins and women who've had complete hysterectomies for non-cancerous conditions being screened - doctors chasing targets and money.
Also, going through electoral rolls and sending letters to unscreened women.
This is but a few of the strategies.

Remember...this is supposed to be an optional cancer screening test - it's unreliable and the cancer is uncommon (always was) AND informed consent is required.

I also believe doctors deliberately chose to withhold any information that might deter women from screening. They exaggerate the risk of the cancer and overstate the benefits and DON'T mention the risks.

The propoganda has worked well though...many women have enormous faith in this test, many believe they were saved by this testing (in fact, the vast majority had a false positive) and many would consider women who don't have tests as reckless and irresponsible. In fact, many women are fearful to admit they don't have smears.
I have watched all of this unfold over the years with increasing horror.
I'm NOT against testing...
I'm against dishonesty and unethical conduct.
If women armed with ALL the facts, still want the Test...then that's fine - they go into the Test KNOWING it's risks and limitations.
Hopefully, more women will eventually get to the truth with more people speaking out.
I think fear will still motivate a lot of women to keep having the test...but at least, they'll be more aware and prepared...and many may choose to have the Test less often to contain the harm.
This knowledge is so important - annual screening means 95% of women face biopsies (with only a very small number having any cancer) and the subsequent harm - Five yearly...55%
55% is still too high IMO, and some women may choose not to have the test until the risk of the cancer is greater than the risk of a false positive/biopsies. (if they had this information)
The amount and type of risk we each carry, is a matter for us.

Sam said...

Just wanted to add:
I'm also very concerned that more reliable and non-invasive tests for cervical cancer are being kept very quiet.
I understand a very reliable and simple blood test was patented in the States in about 2004. Where is it? It's called the Cervical Specific Antigen (CSA) blood test. This test would mean thousands of women would be spared the ordeal of possibly harmful, biopsies. Coverage would also improve, as most women would not object to a RELIABLE and simple blood test.
Can it be the power, control and money generated by pap smears will motivate many to keep out alternatives for as long as possible?

Anonymous said...

Pamela,
I think there is opportunistic exposure of female patients by male doctors and nurses. (the young are at greatest risk)
A male family Dr always pressured my cousins and I to have breast exams at every consultation.
We all refused, but one shy cousin endured the breast exam for years.
Our mothers saw the same Dr and a breast exam was never mentioned. Older women have a much greater risk of breast cancer.

I found out years later that routine breast exams are not recommended for women under 40 in this country and certainly should not be performed opportunistically when you see the Dr for an unrelated matter.

I think doctors and nurses have worked out that sometimes they can take advantage and if challenged by the patient or the authorities, they can put it down to thoroughness or justify their conduct in some other way.
I'm pleased you stopped this male nurse.
I think we should report things like that...bring it home that whether he's being voyeuristic or insensitive, it's unacceptable.
It might make him stop and think next time.

Joel Sherman said...

Here's a link to an article about a Danish study claiming that screening mammography is over used and results in over diagnosis in roughly 50% of cases. I'm not recommending a course one way or the other as I don't feel I'm competent in the area.
But I do note that it's essentially the same controversy that exists for most screening techniques. Prostate cancer is a noteworthy example. Are the benefits in saving lives worth the cost and increased side affects? It's never an easy question and it's hard to pin down the risk/benefit ratio.
For myself I have no doubts; I get regular prostate screenings and don't mind the mildly intrusive exams.

Stacey said...

One thing I've noticed...concerns about prostate screening came out really quickly and men were given access to lots of information about the test...good and bad.
In this case, you CAN make a decision whether to have the test or not.
There seems to have been a concerted effort to push women into screening with virtually no information and no choice.
Most women feel like they have no choice about screening.
I always suspected doctors had plotted against us to force us to have screening.
Since stopping the BCP, I don't have screening.
I never wanted it, but felt like I didn't have a choice.
In fact, I didn't have a choice...if I wanted birth control.
It makes me angry that doctors have gotten away with this for so long.
My younger sister uses the HOPE consult at PP.
Thanks for all the information.
It's shocking this is how we get to the truth.
It doesn't really surprise me.
I always felt we were being deceived, manipulated and controlled to keep waiting rooms full.

Anonymous said...

Surely doctors who force us to have screening without our "informed consent" should be held responsible.
Many of us have been through hell because of this test.
Why couldn't we take legal action?
That would change things quickly...
I've never been given any information or been told anything bad about this Test.
It was just mandatory testing.
You're an idiot if you don't have the test is my doctor's view.
All of my friends have had treatment for things that turned out not to be cancer.
Many of us are so sick of this test that we've stopped having it altogether. It's been 8 years for me. I couldn't take any more of it.
My husband had a vasectomy and I was able to go off birth control.
I'm much happier away from doctors and happy to live with the risk of cancer.
We all live with the risk of cancer but this shouldn't be the focus of our lives. If the testing is making us unhappy or sick, what is the point?

I just don't want to live my life with my legs in stirrups.
We're told this is part of being a woman, get over it.
I totally disagree.
We're adults and make decisions that affect our health every day.
Doctor's don't care about our modesty and feelings or putting us through treatment when the test is wrong.
This cancer screening is wrong on so many levels or at least, the way it is demanded and forced onto us.
It has been a blight on the lives of many women.
They are not doing "just in case" testing on my body any more.
Kate

Joel Sherman said...

I've copied this here from the informed consent thread:

Sam has left a new comment on your post "Informed Consent":

I've been seriously concerned about the ethics and legality of screening practices for decades.
There is lots of evidence to show that screening authorities made a conscious and deliberate decision NOT to disclose to women anything that might deter them from screening.
They also devised strategies to force screening...totally ignoring the need for informed consent.
In countries where doctors are paid large sums to screen 85% of their eligible female patients...this conflicts with the need to obtain informed consent and has led to very unethical tactics and practices.
Also, in the States...where almost all doctors make it a pre-requisite for birth control simply to force screening. It has nothing to do with birth control.
This amounts to coercion, in my opinion...
Personally, I believe no woman can give informed consent at the moment, apart from the few that work in the area or have researched the topic. Any woman harmed by this testing would IMO, have a solid case against the Dr, the medical association and the screening authorities.
I believe that's why they're very reluctant to tell women the truth...when you've been misleading and harming women for years and ignoring the need for informed consent, it's then very dangerous to come clean.
I think a class action might not be far away.
Hazel Thornton, ONE woman, has forced change in the UK...forcing the authorities to release risk information to every woman in that country. It was a fight and it continues....
They have still withheld a lot of risk and statistical information...so the fight goes on.
It shocks me that women have been treated in this way, for so long.
Professor Michael Baum and others have said it's disrespectful...that's putting it lightly!
For those interested there is an article that was published in Australia recently that cautiously discusses some of these issues (authors need to be careful with this topic...any criticism provokes a rapid and savage reaction)
You'll find it at: www.racgp.org.au/afp/200904/200903trevena.pdf

Joel Sherman said...

I have been looking for a summary of Planned Parenthood's HOPE program.
This is all I've found.
Although they will prescribe hormones without an exam, they certainly seem to encourage all women to have them regularly.

Suzie said...

They HAVE to recommend the exams from a legal point of view...I assume because its the standard in this country.
I think HOPE is an indication they understand these exams prevent many women from using OC's or staying on them and some end up with unwanted pregnancies.
Pregnancy has greater risks than no screening.
I think it's also clear many people are starting to question the value of pelvic exams and the way smears are forced on women.
As far as I've heard, they understand if women using the HOPE plan are pressured, most won't return. These women have sought out an alternative and many travel to reach the clinic.
If it's just a way to round up renegades, these women will go back to less reliable methods.
Some women even drive down to Mexico to get the BCP or buy it illegally.
These measures should not be necessary.
I fear doctors may try to shut down HOPE because many women will take up this offer. Doctors have only been able to get away with treating women in this way because they ALL required these exams and did them in the same way - effectively forcing women to comply to their demands. If women have an alternative, their services will not be used as much.
They will lose money and control over women.

The HOPE plan just brings us in line with the rest of the world.
A blood pressure check is all that's required as confirmed by the WHO and many other medical associations around the world.
I'm hopeful this is the the first but major step in breaking the degrading gridlock that has faced women - women just trying to be responsible with birth control.
Many women find these exams unacceptable and remember the victims of sexual assault (a fairly high number of women) would usually avoid these exams.

Once I saw the way women were treated overseas, I knew there were strong motivators and influences in our profession here that have shaped women's health in almost a sadistic way.
Just the way women are examined...asked to undress before the doctor arrives like conveyer belt exams, the use of stirrups that are clearly for the comfort of the doctor with no regard for the dignity of the patient and also clearly used to intimidate and disempower - some doctors also elevate your buttocks to further expose.
Women from other countries are not treated in this way.
The exam is only done when a woman has symptoms - so much less often.
I saw an English doctor last year with abdominal symptoms and needed a pelvic exam. No stirrups (never used)and I did not undress until I saw and spoke to the doctor. There was no need to completely disrobe and I was treated with respect. My doctor said she had never seen stirrups in a consult room in the UK - only in surgery.
This is the way women around the world are treated - these exams are only done when necessary and with the dignity of the woman in mind.
I cannot understand why our doctors continue to get away with treating women without dignity and respect. You often hear talk, complaints, anger and see distressed women and tears but nothing seems to change.
I'm sure men have problems with the profession as well but these exams that are "recommended" from age 18 are damaging and unnecessary.
Women need to just say NO and use the HOPE plan.

Joel Sherman said...

I meant to add above that I tried to find info on the cervical specific antigen. I couldn't find any unbiased medical information. The only article I came across was from the manufacturer who not surprisingly recommends it.
It obviously isn't available in this country. Anyone have anymore info on it?

Jackie said...

Dr Sherman, thanks for the HOPE link.
The bit about the exam that annoys me.
We're all dumped in the same basket. Our lives are all different.
My husband and I have been together since late teens. I don't need an annual physical to look for sexually transmitted disease. I also don't want breast and cervical cancer screening.
Breast exams lead to biopsies and they are a risk factor for cancer. I've had four and no more for me.
My husband and I were virgins so I doubt I've even been exposed to HPV, which they now know causes cervical cancer.
I don't wish to expose myself to cervical biopsies.
I think these lists assume we're all jumping in and out of beds all week. If you are, then you might think some of this checking is a good idea, although every year still sounds excessive.
For the rest of us, leave us alone!

Sam said...

It has been kept very quiet.
You can imagine the money lost if a simple and reliable blood test were available.
I made the mistake of contacting two leading pathology service providers and they both acted dumb and said it wasn't available and was unlikely to be offered in the foreseeable future. I got the impression they defintely knew what I was talking about...
There was an article in Medicine and Man about this test. If I can find the link, I'll post it.
Can you imagine what a difference it would make to women's lives if they could be tested in a non-invasive and reliable way?
If doctors were really concerned about this cancer, they'd be fighting to find out about this blood test. They could achieve very high coverage...most women wouldn't object to a reliable blood test. It would also mean all the women having biopsies and treatment would be spared...
Only women with a real problem would be referred...
This also means a LOT fewer women having biopsies, so MUCH less work for specialists.
When you take this testing, biopsies and treatment (for things that turn out not to be cancer) out of the equation, it would be a HUGE chunk of income gone for lots of doctors and health care service providers. (pathologists, day procedure clinics)
I've managed to get a copy of the Patent...that's about it.
I've also sent a few letters off to health action groups.

Joel Sherman said...

Well if you find a good link on cervical specific antigens please post it, Sam. But a few further comments: If the test was good, you can be sure that the manufacturer would be pushing it hard, because big bucks could be made. The medical establishment couldn't easily stop it, and I don't think they'd want to.
But even if CSA is approved, don't expect too much from it. There are almost always false positives and negatives. Prostate specific antigen has been a boon for prostate screening, but it has not decreased the incidence of biopsies. In fact it has greatly increased the use of biopsies, many of which are negative.

Sam said...

I'm hopeful it's more reliable than the current test.
I wish I could be as confident that the medical world would embrace a new simple and reliable blood test.
A friend who works in health economics told me the large pathology houses would lose 50% of their income if the pap smear was discontinued.
He also calculated specialist and day procedure clinics that handle the thousands of false positives would lose heaps.
Although....a US colleague said insurance companies would push the test through in the States. They would welcome any cheaper option that also reduced the number of women having biopsies and treatment.
I hope he's right.
It wouldn't take much to be more reliable than the current test which relies on a pathologist viewing the sample.
One of the reasons increasing numbers of women are having biopsies is the caution of pathologists....with Pathologists being sued when they miss something, they're leaning more and more on the cautious side.
This means more healthy women having biopsies.
From their point of view, it's better to send a woman for biopsies than risk legal action.
An alternative to this test is desperately needed.
It worries me there has been so little discussion about this test...either way...promoting or condemning it.

Joel Sherman said...

These 2 posts copied from the personal privacy violations thread.

Elka has left a new comment on your post "Add Your Personal Story of Privacy Violations":

It is puzzling this yearly stirrup exam that American women endure.
In the Netherlands, the prostitutes of the red light district in Amsterdam are offered cervical screening no more often than other women. Tests are offered from the age of 30, 5 yearly until an age settled with your Dr...sometimes 50, 55 or 60.
No later than 60.

Prostitutes would have the highest risk of this cancer.
The doctors know however, that it's still a low overall risk.
It's not a very common cancer like lung or breast cancer.
They've worked out testing before 30 or too often causes serious problems for women, even in this high-risk group.
American women would surely face many harmful investigations when they start so young and having it every year.
No wonder you are concerned with this state of affairs.
I hope you can change things.
Can't you point to other countries who don't test so often and have no more or even less cancer than the States?
The extreme yearly gyn. exams pressed on American women are not done here, not recommended or offered.
I'm 38 and have never had a pelvic exam.
Of course, no woman is forced to have any test. It's up to you.
My doctor thinks smoking is very bad but isn't worried about women not wanting cancer screening.
She thinks smoking is the worst thing you can do to your health.
Our doctors don't seem to be concentrating on this cancer and are more likely to focus on your entire lifestyle choices.
Safe sex, smoking, weight, alcohol consumption, exercise, eating a balanced diet, sleep patterns, stress levels.
Perhaps, that is just my doctor, I doubt it as my friends tell me the same thing.
No woman needs to stay away from her doctor if she doesn't want this test.

-----

I don't see this as a male v female issue.
It's disappointing to read men dismissing a violation of a woman's privacy.
I sympathize with ALL patients who have their privacy violated...men and women.
We should all stand together on this issue.
I see us all powerless in the medical setting.
It's very hard to make a stand in a setting where the system has all the power.
I have read that men and women in the military are treated like cattle.
I even read a male gynecologist saying he'd always get work in the military where women have no choice of doctor. That shook me, that he'd be happy in those circumstances...callous and uncaring if you ask me.
I feel angry for all people treated disrespectfully.
I believe these people will only change their ways when they face serious consequences for inexcusable breaches to our privacy and dignity.
People in the military and everywhere else should be treated the same way...respectfully and intimate exams should always be carried out privately with same sex doctor. (if requested)
These exams should also only be carried out if necessary and only with patient consent. I don't believe military men or women should be forced to have smears or prostate tests. (unless they ask for them - they should be optional extra's)
I also disapprove of the stranglehold on women and contraception in this country.
I won't allow myself to be manipulated in that way, so condoms and natural methods will have to do.
I will look into this HOPE alternative and would even drive or fly to another area to get access.
My husband would love a break from condoms.
He understands why it's necessary though.
If I were facing all of that every year, I'd prefer not to have sex.
LH

SMc said...

None of this is a surprise.
Historically, women have been treated very badly by the profession.
The thing that upsets me, is that it continues despite so many female doctors now involved in our "care".
I read something recently that really played on my mind.
Did you know that American brides were required to have State mandated pelvic exams during the Cold War?
The hair brained idea was formulated by male doctors who thought a young woman's reaction to vaginal penetration would give them some idea whether she'd make a good wife.
How you can compare penetration by a doctor and medical instrument and making love with your husband, is beyond me.
Many women where traumatized by this exam.
Naturally, the men or grooms were only required to have a blood test. No genital violation for them.
I saw a post from an older woman on a childfree site talk about her ordeal at the hands of a doctor and his assistant. She was 19 and held down physically and forced to have the exam when she objected...
What a brutal introduction to married life?
If the woman was actually held down, this matter should have been referred to the Police.
Even a State mandated pelvic exam would not permit a Dr to use force. There are very limited occasions when force can be used.
There were few checks back then and doctors got away with disgusting treatment of women.
I needed to know more about this abuse and hoped it was all untrue or exaggerated.
Sadly, it's all true
You'll find a summary of this pre-marital pelvic exam in "Waking Sleeping Beauty" by Carolyn Herbst Lewis muse.jhu.edu/journal_of_womens_history/v017/17.4lewis.html
It made me feel ashamed and disgusted.
I believe these women could have taken legal action against the Government and probably, still could, for the violation of their civil rights.
I think these State mandated exams amounted to sexual assaults.

The abuse still goes on, just achieved a different way and justified differently. A woman seeing a doctor for the Pill prior to marriage would usually face a pelvic and all the rest.
It's all supposed to be for the good of our health, THEY know best.
I have always been deeply suspicious of doctors.
The more I know, the more careful I am to protect myself.
HOPE at Planned Parenthood will hopefully, change all of that...
Women may finally have a choice and can take back control of their bodies.

Joel Sherman said...

SMc, that url did not work. Could you recheck it.
I never heard of mandatory premarital pelvic exams though it is believable that some states required it as part of premarital VD exams. No federal law could apply.
It reminds me of the premarital exams that potential queens underwent in Europe to try to prove that they could give the monarch an heir.

SMc said...

http://muse.jhu.edu/login?uri=/journals/journal_of_womens_history/v017/17.4
or,
lewis.htmlhttp://muse.jhu.edu/search/results

Dr,
This contains a brief summary of the reasoning behind the exam.
There are extracts from the article available elsewhere on the Internet...if you google the authors name together with a catch word like pelvic exam or premarital exam.
It still shocks me that someone convinced the authorities that this was a good idea.
The damage it must have caused...
Of course, the women would not be expecting this exam, just the usual blood test...I'm sure that would have added to their trauma.
It made me think that women's bodily privacy has often been violated for absurd reasons and unnecessarily...
Even today, when the rest of the women in the world can access birth control easily, we face substantial medical barriers.

SMc said...

1. Waking Sleeping Beauty: The Premarital Pelvic Exam and Heterosexuality during the Cold War
Lewis, Carolyn Herbst.

Journal of Women's History, Volume 17, Number 4, Winter 2005, pp. 86-110 (Article)
DOI: 10.1353/jowh.2005.0051
HTML Version | PDF Version (162k)

Subject Headings:

Premarital sex -- United States -- History -- 20th century.
Orgasm -- Moral and ethical aspects -- United States -- History -- 20th century.
Throughout the 1950s and 1960s, physicians writing for American medical journals created a vision of female heterosexual health that linked vaginal orgasm with marital stability and community security. This article focuses on how physicians sought to ensure healthy female heterosexuality through the use of state-mandated premarital consultations. Physicians repeatedly asserted that by monitoring a woman's response to penetration during a premarital pelvic exam, they could anticipate her ability to experience vaginal orgasm during intercourse. A sexually fulfilling relationship, physicians explained, was the foundation of marital stability. These marriages would then serve as the building blocks of a morally, and therefore politically, secure nation during the early decades of the Cold War.

Thought I'd paste this across...in case the link is still unclear.

Sam said...

Link to Dixon article mentioned in my post...."Pelvic exam prerequisite to hormonal contraception: Unjustified Infringement on Constitutional rights, governmental coercion and bad public policy" by Heather Dixon.
http://www.law.harvard.edu/
students/orgs/jlg/vol27/dixon.pdf

Joel Sherman said...

I've read through the Dixon article and independently looked up some medical facts. I'm not a lawyer and can't judge constitutional law, but medically the article seems basically correct. There doesn't seem to be a valid medical reason for requiring a pelvic exam before starting contraception. Contraception may increase the incidence of breast cancer, but a pelvic won't help detect that. Its association with cervical cancer is apparently not strong enough to warrant a requirement. There are of course other medical contraindications to its use, but none are clarified by doing pelvic exams. Here's a brief lay reference. Wikipedia gives a brief summary of cancer risk.
Based on what I've read, I would agree that it is not unreasonable to give hormones to women who refuse exams.
I was unable to find the historical article on cold war practices. A librarian couldn't come up with it either.

Joel Sherman said...

Oops, my mistake. The librarian did find the cold war article. It's long. Will take me awhile to get through it.
But the articles quoted go back to the time I was a medical student. As I never heard of the theories before, you can be sure it didn't have much impact on American medicine.

Sam said...

Dr, can you then tell me why almost every Dr in the States makes full gyn exams a pre-requisite for birth control?
The medical evidence doesn't support the need and these exams are not carried out in other countries.
Have doctors decided to write their own rule book in violation of womens rights and bodily privacy?
Why?
Power, money, control, fear of litigation???
The end result - a woman who refuses to go through the most invasive exam in the book, is DENIED reliable birth control.
Why isn't this on the front of every newspaper in the States?
This should be a matter of absolute outrage for every man and woman in the States.

Joel Sherman said...

Sam, I can only surmise.
Traditions take a long time to change, especially when legal liability issues are present.
When the various professional societies revise their official recommendations, change will occur more rapidly.
Thirty plus years ago when I was in training and starting out, the hospitals I worked in had a policy of requiring complete physicals on all admissions. Don't know whether that was a JCAHO recommendation or a state regulation though it occurred in several states. That included doing pelvic and rectal exams on all admissions whether or not it was really pertinent or previously done on the outside. Even patients on the psych ward got full physicals. Never really did understand the rational for that. Nowadays the emphasis is not on thoroughness but on outcomes and cost. It's not a change that's all for the good.

Hexanchus said...

Joel,

Another thought....do you suppose they might be able to bill more for the complete pevlic/PAP/etc. than a simple 15 minute consult?

At the risk of appearing somewhat cynical, I think that "Follow the money" might be one way to look at it. Multiply the cost of supplies, lab tests, etc. per exam times the millions of women using hormonal contraception and we're talking some serious dollars. The labs, pharmaceutical companies and medical supply manufacturers that supply these goods and services would hate to see this segment of the market shrink and I'm sure they lobby hard to prevent it, and even to increase it - witness the TV add that pushes the "a PAP isn't enough, you need the HPV specific test" theory to the consumer.

Joel Sherman said...

I thought of that question Hexanchus before I posted. It's certainly a fair question. I asked my wife if she ever gets separate bills for a pelvic exam when she sees her gynecologist. She said no, but it is still possible that the visits are coded at a different level when a pelvic is done which she wouldn't necessarily be aware of. Even if there is an additional charge, which I believe would be justified, the physician may still not be making much additional profit as every pelvic exam involves sterile equipment and a both a physician's and assistant's time for at least an extra 15 minutes. My guess is that the money at best is a minor factor.
Maybe some of the women here can describe how they get billed with and without a pelvic exam.

Sam said...

Thanks Dr Sherman...

"When the various professional societies revise their official recommendations, change will occur more rapidly."

I just wanted to mention that the USF&D Administration, WHO, Planned Parenthood and the American College of Ob & Gyn's all say pelvic exams and cervical screening are NOT required for hormonal birth control.
Dr Robert A. Hatcher who gives advice on "Managing Contraception" also agrees they're not necessary.
Surely all this means Doctors are ignoring these recommendations?
I think that's unusual - usually doctors seem careful to follow guidelines so if something goes wrong they can point to the recommendation.
Wouldn't their continued blatant disregard of these recommendations leave them wide open if a woman was harmed psychologically during the exam or was harmed in a follow-up procedure following a false positive test result.
Wouldn't this point to a vested interest of some sort on the part of the doctors?
What more can be done to force doctors to comply with these recommendations?
It seems to me there are powerful forces at work quashing any move to loosen the medical profession's hold over birth control (and women).
That's certainly the way it seems - you find agreement from all quarters, but nothing changes and women still hit brick walls every day.

Hexanchus said...

Joel,

I wasn't thinking of the billing issue strictly from the physician's standpoint, although the clinic does typically make a percentage on everything they provide, even pass through tests. My primary point is that there is a medical industry out there that has a vested financial interest in these exams.

So how big are the numbers we're looking at? I did a little research and was able to come up with some hard numbers:

1. Based on a comprehensive study done in 2002 there were 62 million women of child bearing age (15-44) in the US. Of those, 14.3 million currently used a hormonal form of birth control (oral contraceptives - 11.8 million, other forms (patch, injection, implant) - 2.5 million.

2. The actual cost to the patient (non-reimbursed or subsidized) of a basic office visit I was able to find varied widely, but the predominant average seems to be in the $60-$90 range for your basic 5-15 minute consult with no tests.

3. The actual cost to the patient (again, non-reimbursed or subsidized) for a complete pelvic w/PAP ranged from $175-$275.

4. The range of actual cost for a PAP test is $47-$75, depending on which test is used.

Now let's do some calculations:

To be conservative, if we use the lowest numbers in the ranges from 2 & 3 above, the difference in cost for annual pelvics w/PAP vs. a basic consult without exam for women using hormonal contraception in the US is over $217 million annually. This is not exactly chump change! Based on the hard scientific data, virtually all of these exams are unnecessary, but even if you were only able to eliminate 75%, we're still talking some serious dollars.

Now let's look at time savings. The office visit with exam typically takes about twice the time as a basic consult (30 min vs 15 min). The potential difference is 3.625 million provider hours annually. Even if you could only effectively recover half, that's almost 2 million additional 15 min office visits that could be accommodated.

So we're talking not only real reduction in costs, but also freeing up provider time to accommodate more patients. Looks like a win/win scenario to me! I wonder if President Obama's task force has tripped to this yet?

Hexanchus said...

Oops!

I messed up the calc on the time savings - 3.6 million hours x 2 15-min visits per hour(50% recovery) = 7.2 million additional available visits - my bad.......

Joel Sherman said...

Sam,
Most physicians would be willing to follow the recommendations of the College of OB-gyne if they knew about them and were satisfied that their legal risk was minimum. You possibly could even have a role in changing attitudes if you wrote to the college and asked them to make the change in their position more widely known through editorials or position papers in their journal. You could do the same for the AMA and the American Academy of Family Physicians.

Hexanchus, I don't think the average physician in practice pays much attention to how much money outside corporations make. It wouldn't affect 98% of us at all if say the industry that supports pap smears should crash.
Thanks for your financial estimates. Bear in mind though that many ob-gyne offices could probably see an extra patient in the time it takes them to do a pelvic exam so they could make up that money easily. Most generalists that I know (and that may not be a representative sample) try to avoid doing pelvics in the office as they are too disruptive to their main routine. They try to refer them to gynecologists.

Sam said...

Thanks for the figures and your comments.
I'll send off a letter, but I've found medical associations refuse to address any criticism or entertain any suggestions for change. They just send back the standard patter letter. I call it the propaganda, "essential to every woman's health" letter.

Also, when we're talking about money, remember to factor in the 95% of US women who face cervical biopsies in their lifetime.
Some of these are done in a gyn's rooms, others require a hospital stay (usually day procedure with a general) for things like cone biopsies.
A % of women will be left with permanent damage causing infertility and difficulty during pregnancy.
Some women need surgery to stitch the cervix closed to maintain the pregnancy - the pregnancies become high risk - all of this means BIG dollars.
AND on-going dollars as a % of healthy women are turned into unhealthy women.
I've read these women may have problems into middle and old age as a result of this damage.

The overwhelming majority of these biopsies are for false positives or for things that would never turn into cancer. Only a very small number will have actually had a problem.

This is unavoidable when you have an uncommon cancer and an unreliable test - when you test young women and test too frequently, you cause more harm than good.
Some say if this Test had been properly evaluated, it would never have been acceptable for mass screening - because of the harm it does to healthy women.

Also, I've read the pathologists would lose millions if this test was done less often. It accounts for a huge % of their income.

In the States, women on average have 55 or more smears over their lifetime (some many more) - other countries it ranges from 25 down to 5.
Ironically the 5-7 tests comes from the country with the lowest rates of cervical cancer and biopsies (and false positives)- Finland
So, all of these tests do NOT benefit women...in fact, I'd argue women are seriously disadvantaged by the testing. They are overtested and overtreated to their detriment often, CAUSING health problems.

I'm not sure why women's health is treated so differently in countries like the Netherlands and Finland.
Complete honesty and free exchange of information, doing what is best for women and always respecting a woman's right to choose. An acceptance that it's her body and she has the right to make her own decisions.

In the States (and other countries) women are almost afraid to refuse this testing. It seems like scare campaigns, overstatements, exaggerations and no risk information is the standard...to force compliance in complete disregard for women's health.

The US is not alone there - but it IS alone actually pushing women into routine annual gyn exams and making these exams and screening a pre-requisite for birth control. In other countries (except Germany) these annual exams are considered unnecessary in asymptomatic women and are regarded as possibly, harmful.
In the States, enormous pressure is placed on girls and women to have these annual gyn exams - some parents take their daughters in for her first gyn exam as young as 13. These exams can lead to further investigations - more money, more harm.
These exams are totally unnecessary and causing enormous harm.
The US system seems a "we know best, do as you're told" attitude(even if it doesn't make sense) - "we can ask you to jump any hurdle we choose to create, simply because we're doctors and have the power"...
It's seems arrogant, paternalistic and it's definitely unethical...it might also be illegal.

Personally, I curse the day this issue presented itself to me...I have felt such outrage on behalf of the women conned and harmed by all of this....and have never felt stronger about any issue.
I can't bear unfairness, particularly, when it involves a very vulnerable group.

Joel Sherman said...

I finally read the article "Waking Sleeping Beauty" by Carolyn Herbst Lewis that SMc recommended.
The article continually refers to physicians in general but nearly all the references come from psychiatrists, not GP's or gynecologists. I was married in the 60's and my wife says there was no mandated pelvic exam for premarital testing, only blood tests for VD. She did have an exam before starting contraception though, but that was unrelated.
The 50's and 60's were in many ways the hay day of Freudian psycho-babble, at least that's what I would term it. As a med student in the 60s we were not taught any of the philosophies purported to be in practice in this paper.
In short, I would suggest that this paper describes a passing fad among psychiatrists which was never put into practice by the medical community.

SMc said...

Perhaps, it was only in certain States, but I read an account on-line from a woman who'd been put through the exam.
It would be interesting to know just how widespread it actually was...
How many women were affected...and why it stopped...Did someone seek legal advice?
Reading through the article, I had to keep reminding myself that someone or a group actually convinced the authorities that this was a good and worthwhile thing to do to young women.
I can't help but think that "climate" has fostered the problems women still face today with the medical profession.
Thank you for taking the time to read the Article - much appreciated. I understand your point...perhaps this was psychiatric research, but to make something like that mandatory is hard to fathom. I would have thought the ethical and proper thing to do would be to call for volunteers etc...
I think the account by the older woman would be fairly easy to find - it was a childfree site.
I wonder whether this experience played any part in her decision not to have children....which is usually a very medical process and very hard to manage with serious trust issues.

Joel Sherman said...

Sam, do you perhaps have a reference for the harm that cervical biopsies do?
I'm not familiar with much of what you say.

Joel Sherman said...

SMc, one further point. I did not get the impression from the article that the premarital pelvic exam to foster healthy coitus was mandatory anywhere. Some doctors may well have pushed their patients into it, but I'm not aware of mandatory state laws to that effect.
Remember according to the article, the physicians advocating the pelvics were mainly psychiatrists, not physicians who actually did the exams. Most doctors were probably like me; I never took the recommendations of Freudian psychiatrists seriously.

Sam said...

I have lots of articles about the harms of cervical screening.
I'll go through my stack and post a few links.

Raymond said...

Just to add to comments on cervical screening.
Your chance of benefiting from screening ARE small (and tiny in low risk women) and your chance of a false positive and biopsies in your lifetime very high.
You might care to look at some statisitics put together by Andrew Rouse, Snr Lecturer in Public Health at Birmingham University.
What is the likely benefit to a woman submitting for a pap smear?
Look at the chance of a woman surviving 10 years if she does - or does not - have routine smears.
It is clear that the absolute benefit to an individual woman is small.

Age at start of 10 year period: 25
No of women alive at start of 10 year period: 10,000
Alive 10 years later if they have smears: 9963
Alive 10 years later if they don't have smears: 9962

Several countries do not screen women younger than 25 or 30 based on the very low risk of cancer and high chance of false positives.

Age at start of
10 year period: 35
10,000 women...alive 10 years later with screening: 9863
Without screening: 9859

Age at start of
10 year period: 45
10,000 women...alive 10 years
later with screening: 9713
Without screening: 9708

Age at start of 10 year
period: 55
10,000 women alive 10 years
later with screening: 9457
Without screening: 9450

Factor in the inaccuracy of the test...
7% recalled due to inadequate sample.
5-15% of abnormal smears are reported as normal (per test...called false negatives)
The colposcopy rates have been quoted elsewhere - 95% with annual screening (over a lifetime)
Almost 78% with 2 yearly testing
65% - three yearly
55% - five yearly
So, we can say fairly high numbers of false positives.

I agree, that no woman can currently give informed consent for this testing.
This information is not made available to women.
If it was...some women might choose not to be tested...particularly low risk.
Others may choose to lengthen the time interval between tests to lower the risk of a false positive.
It seems clear the current promotion of this screening test overstates the risk of this cancer and the likely benefit/value of the testing and doesn't adequately inform women of the high chance of an incorrect test result and its likely consequences.

This information is taken from
http://www.bmj.com/cgi/
eletters/320/7238/872

Raymond said...

Please note the % of false negatives is an "at least" figure...so the actual % is likely to be higher.

Joel Sherman said...

Thanks for that link, Raymond.
The letter does indeed give very interesting data which supports the opinions voiced here that pap smears should be optional and based on fully informed consent.
I do note however that this is a letter and a full paper documenting how they derived those figures would be even more convincing.

Ruth said...

I have always regarded smears as optional.
I knew deep down that this testing didn't make sense for most women.
I looked at the women from earlier generations in my family and others...no cervical cancer.
I was told the sexual revolution would lead to an epidemic.
I'm not sure about that, but given I wasn't participating in the "sexual revolution" I couldn't see how it was all that important.
When my Dr told me "every woman is at risk"...I suppose if you have a cervix and have had sex, that's true.
I do know that most things have degrees of risks.
When my risk was low, I passed on the Test.
It was only later I found out that most women having this test would end up having biopsies.

I think the willingness of doctors to push this sort of exam on women with so little information and no regard for our wishes and right to choose IS unacceptable. It shows a blatant disregard for our modesty and dignity.
The attitude seems to be that women will accept this sort of exam because we go through childbirth or we should get used to this sort of exam.
Rubbish...

When a patient, male or female, can see the need for an exam, they're more accepting.
When they're perfectly healthy, given no information and asked to expose themselves fully...that's another matter entirely.

It is reassuring however to read just how few benefit from this testing and upsetting at the same time.
I think doctors dismiss our modesty concerns and consider biopsies a minor procedure.
Having seen most of my friends go through this procedure, I can tell you women do NOT regard this procedure as minor.
I followed my instincts intially and now I see the facts that back up my early suspicions.
I think this focus on cervical cancer has diverted much needed funds from more important areas like heart disease. We lose a huge number of women to heart disease, yet it's rarely mentioned.

Anonymous said...

In British Columbia, Canada they're trying to increase the number of young women getting tested.

http://www.womenshealthmatters.ca/ubbthreads7/ubbthreads.php?ubb=showflat&Number=11910&page=1#Post11910

J.

Sam said...

IMO, tragic cases make bad health policy.
In Australia, there is some media coverage of a 21 year old girl with cervical cancer. She had a smear which returned a false negative, so it was another 6 months before she was diagnosed...I assume because of symptoms. Without the smear, she may have been diagnosed earlier.
Some women are reassured by a false neagtive and delay seeing a doctor for symptoms.
The smear may have disadvanatged her.
Yet the doctors never make this point....they have an amazing way of using this point to call for more frequent or regular testing...because the test is so unreliable, we should play jeopardy until it gets it right.
They never question the value of testing....always reinforcing the point that testing is vitally important...regardless of the outcome.
So now lots of young girls will be rushing to the doctor for smears.
This is a very rare case - she's the youngest to ever be diagnosed in that country. (I think)
Girls being tested means lots of false positives and damage to the cervix...causing problems with infertility and during pregnancy. (& other problems)
Many countries don't test young women because of the high chance of intervention for false positives.
Rare cases are tragedies...and should never shape health policy.
In the law there is a saying, "Hard cases make bad law"...it equally applies to medicine.
In the UK, a young woman died of cervical cancer this year...Jade Goody. Her fight attracted enormous media coverage and a call to lower the age of testing from 25 to 20...
Thankfully, they've decided not to lower the age. Sadness and fear caused by a tragedy should never override commonsense.
I think lots of young women just got lucky.
Testing has risks at any age, but testing women under 30 is IMO, just reckless and cannot be justified.
Great information, Raymond.
I've seen similar studies over the years. When you compare the enormous emphasis placed on this testing, the huge resources that go into it and the scare campaigns...it just doesn't make sense when you look at the statistics.
I cannot understand how this test was ever approved for mass screening.
I can only think governments were seriously pressured by interest groups and others saw a huge financial advantage.

I haven't forgotten the references re biopsies...I'm working away from home at the moment, but I'll access my reference file later in the week.

Joel Sherman said...

This is duplicated here from the informed consent thread:

Bree has left a new comment on your post "Informed Consent":

I agree...we are given no choice about smears and gyn checks...we're TOLD, DIRECTED, it's INSISTED upon or just done...
Only the strongest women can avoid them.
I just stay away from doctors and rely on the pharmacist to meet my needs.
I'm happier and healthier than all of my friends that go through the annual cancer-checking process...they often take Xanax to get through the exams and then there is the awful things that usually follow...vaginal ultrasounds and biopsies. The extreme fear and anxiety, the humiliation and degrading nature of the procedures.
They have all (but one)had bits carved out of the cervix, or burnt off or frozen off...you can't tell me that all of these 20-something women had cancer or were in real danger of it.
Everything seems to be pre-cancer - it seems all of us are pre-cancer except for those of us who walk away from this shocking "treatment".
All of my friends who've been convinced of the need for this exam or were pushed into it carry the scars and they're only in their mid to late 20's. Several have been told they'll need special care if they get pregnant because they now have an incompetent cervix.
What are we doing to our healthy women?
It never seemed right to me...our grandmothers and great-aunts didn't live like this and in most cases, they lived into their 80's.
I think this obsession with cancer has turned our lives into a suspended state - the assumption is we all have cancer until proved otherwise...by checking, cutting, burning and freezing.
I will never live my life with that slant...
My fear of that life is far greater than my fear of cancer.

Joel Sherman said...

I don't like to comment too much on these topics because I have no expertise in the field. But there have been several posts claiming that cervical biopsies can lead to cervical incompetence which is a major obstetrical complication.
So I've checked several references. This one is perhaps the clearest stating that routine cervical biopsies do NOT cause incompetence. I believe they are referring to the usual punch biopsy. More extensive procedures such as cervical cone biopsies can, but they are not usually needed, perhaps only when there is a high level of concern that a malignancy is present.

Amy said...

My sister had a cone biopsy...no cancer was found...she had her cervix sutured closed so she could carry her son to almost full term.
Her gyn told her that damage and scar tissue following cone biopsies and LEEP OFTEN cause infertility and problems during pregnancy.
Her specialist gyn (high risk preg) confirmed that fact.
She said that unfortunately that was the major down side to screening.
Quite a few of my sister's friends are worried about facing the same problems...they have also had cone biopsies or LEEP and some have had more than one biopsy.
The curious thing was...especially after reading this blog...that my sister had her cone biopsy when she was still a virgin. Her doctor said she had to have a smear as she was taking BCPills for painful periods.
The test came back abnormal...it was a scary thing for a 20 year old college student.
Even though it seems perfectly clear that virgins don't need smears...looking at various medical websites they still seem to say that you should have your first smear by age 21 whether you're sexually active or not...
That seems negligent to me.

Anonymous said...

Dr, look at the number of women in this country having cone biopsies and you'll be surprised.
Most have no malignancy at all.
This is a major problem.
I suspect, once again, its overtreatment to minimize the risk of a law suit.
Des

Joel Sherman said...

Thanks for the comments. It is clear that in order to make an informed decision about whether a cervical biopsy is needed you need to know all the facts including what type of biopsy is being recommended.
The onus on supplying this info must come from the doctor as the average patient could not be expected to know enough to ask the proper questions.
Unfortunately to receive the best possible care, you need to do your own research. That applies to all situations, not just this one.

Amanda T said...

Having worked at women's health clinics and gyn offices in both the UK and the States....I can say the US situation was so concerning I resigned and chose instead to take a clerical job offering less money.
I wanted to nurse in women's health to care and help women, not dictate and damage them.
Any criticism or concerns were instantly dismissed by the doctors.
You test virgins and young women, you test far too often and this means LOTS of women facing the horror of an abnormal smear that turns out to be a false positive.
Of course, the poor woman has a lot of time to consider her future...waiting for the colposcopy and pathology.
It is terrible to see their fear and embarrassment. These exams and procedures are far from easy for any woman.
I felt uncomfortable with the lack of information given to women, the way they are simply processed with no one free to decline any part of the exam or test.
I also noticed the high number of women sent for colposcopy and lots facing the more extreme biopsies.
I don't believe this is an acceptable or humane way of treating women and I couldn't be a part of it.
I have been seriously disillusioned with the medical profession.
The really painful thing...so many of these women are so trusting of doctors and suffer as a result.

Joel Sherman said...

This is a post I just received:

Anonymous has left a new comment on your post "Women's Privacy & Modesty Concerns":

Other than not giving birth control pills, how are women "forced" to submit to those unnecessary exams? It sounds like just as many female doctors try to force the exams on women as male doctors. They can't all have voyeuristic motives.


But yes, the whole point is that many doctors will not prescribe contraceptive pills without a pelvic exam. That is a form of coercion if it's not medically required. I don't think any poster here claimed that it had anything to do with the physician's gender or voyeurism. Women providers have been taught the same guidelines as men. I believe a significant proportion of women find a pelvic exam abhorrent no matter who performs it.

Erin said...

Exactly...the withholding of birth control until you submit is coercion and puts us in third world status in my opinion...
We fought for our rights on many fronts but can't access reliable birth control unless we agree to optional cancer screening and unnecessary gyn exams that are not even recommended overseas.
ALL cancer screening has risks and that's why it's the person's decision to review their situation and decide whether they'd benefit from it.
It's only when we work overseas that we see just how outrageous the situation is in this country.
I become so angry and disgusted it becomes difficult for me to discuss my feelings with doctors...I just want to scream at them.
Many say they agree with me...the gyn exam is of very low clinical value and they know it's not recommended overseas BUT they have to follow the protocol here...yet when you look at the medical associations they all say this exam and the smear are not required for birth control.
You end up going around in circles fighting for access without these requirements.
We are talking about the most invasive exams in the book, the most invasive and we're asked to have them when there is no reason, and a basic human right...access to birth control...is denied or stopped until we agree...
I love this country...but feel deeply ashamed that all of this is acceptable to so many people or that so many people simply don't care...

Anonymous said...

Dr. Sherman,

I share the frustrations of many of the women here. Instead of proving us with all pertinent info, many of our healthcare providers attempt to pressure, shame or frighten us into having certain things done. No discussion, no giving of information, no weighing of options, no opportunity to decline.

Several months ago, I visited the OBGYN because of a lump (or what I had thought was one). All turned out OK in that regard, but it is what else that happened during my visit that has upset me. I was not only was kept waiting alone in the exam room for more than two hours (Dr. was not delivering or in surg. that day, just merely running late) but was also scolded by the receptionist when I said I was nervous. Instead of trying to reassure me because I was scared about the lump situation, she said "Shame on you" and scolded me because it had been awhile since I had seen that particular Dr. ( I also am a patient of a general practitioner -- more on that later)

I lost my mom to brain cancer nearly two years ago and since her diagnosis and death, I've become absolutely terrified of anything having to do with cancer. I was terrified that day because I thought I had a lump and had something wrong with me. What I didn't need was the admonishment from the receptionist.

Well, after a long wait alone in the exam room, the nurse came in and, without a word, began laying out the tools for a pelvic exam and pap test. She wasn't very talkative or friendly and when I questioned what she was doing, she just said I needed to have that done, no ifs, ands or buts. That wasn't the purpose of my visit, not the reason I gave on the phone for making the appointment and I did not request that exam once in the office. I sure as heck was not up to that, given my other concern. I was frightened enough as it was without having that thrown at me. I managed to get out of having the exam done because I said it was that time of month and I had cramps, which was true. I just think it never should have been brought up and the nurse never should having been laying out those tools when that was not my reason for visiting.

The Dr. and nurse did not let me out of there without a stern warning and saying they'd be far more frightened about cervical cancer than the other, even though that was not the purpose of my visit. I am a virgin at the ripe old age of 32. Hard to believe for some folks, I am sure, but it is true. I have read in many places that such exams may be of little clinical value for virgins (I believe the Mayo Clinic folks have said something to that effect) and so I resent that so many Drs., including mine, assume we're all sexually active and in need of such invasive testing (I have had this test before, by the way).

Also, it bothers me that every time a woman goes to the Dr. (at least in my experience) the subject of paps and pelvics is brought up, no matter the reason for her visit. My GP has even done so and I don't appreciate it. If I make an appt for a sore throat, that is ALL I want to talk about.

Anonymous said...

Hi,

Whilst not a woman, I thought readers to this section might be interested in this Austrlian study, which goes to the practice of pelvic exam, even when it is recognised that they are for most of little value.
http://www.racgp.org.au/afp/200806/25071

Chris

Anonymous said...

Dr. Sherman,

I wrote my previous post in haste, so I forgot to add something. Sorry for being so long-winded.

Anyhow, I forgot to mention that in said OBGYN's office, the exam table was angled in such a way that in was right in front of the doorway in full view of whomever might happen to open the door. Anyone could have walked back there and opened the door to see someone's private area being examined. I think that is wrong and an extreme violation of privacy.

Anonymous said...

THAT is why I avoid doctors.
We have no rights in the consult room. It doesn't matter why we're there...it's pelvic and pap.
I hate the scenes so now choose not to see doctors at all.
Just one point...no country in the world recommends pelvic exams or paps for virgins - none!
Also, it's true....pelvic exams are not recommended in other countries.
My friends in the UK have never heard of them. There is a fair bit of criticism of pap smears over there as well.
You'd be shot at dawn if you dared criticize the pap smear in this country.
It's just our doctors who have decided to make these things mandatory regardless of need, ethics, patient choice and the law.
I tried shopping around for a doctor before giving up about 9 years ago.
What a shocking state of affairs....but I don't see it changing anytime soon.
The doctors have the power.
Every time they treat us this way, they drive more of us away.
BTW brain cancer is much more common than cervical cancer...lung cancer and heart disease too...never hear about them
BUT cervical cancer which is uncommon...never hear the end of it.
Erica

Gilly said...

Thank you Erin and Anon,
I'm not alone.
I don't mention it to friends and family but I also don't see doctors.
I was berated to the point of tears...called a stupid girl...and told when you die, don't blame me...when I refused all of this when I was an 18 year old virgin.
I was getting recurring headaches and nausea...it must have been my exams because it passed...I didn't get any treatment because I left the consult room before it ended...
It was so frightening I felt sick for weeks.
I haven't seen a doctor since...just the thought makes me anxious.
Men are able to see doctors without intimate exams being demanded of them...I wonder how many men get shouted at...
I guess we're easy targets.
The doctor said they'd get me when I needed birth control.
That will never happen...

Joel Sherman said...

I want to thank all the posters here for their comments.
Your messages are clear. Women are not asked what kinds of exams they want or need.
Clearly you may need to be aggressive to obtain the kind of care you desire. Most of you who write here have learned that lesson. However I'd encourage you to discuss it with your doctors, not to avoid them. That's what men are accused of doing.
I've read enough now to agree with you that routine yearly pelvics and paps are optional for women without specific indications.

Gilly said...

It's the aggressiveness, Dr...the way they speak to us.
Seeing a Dr becomes an ordeal...never knowing whether you'll be strong enough AGAIN to avoid these intrusions.
I think we should all report these doctors...our complaints may fall on deaf ears, but the fact remains...I've read here and elsewhere that doctors must legally obtain our informed consent and that when harassment and intimidation are used these doctors are breaking the law and ethical codes.
I feel like I have no rights at all in a consulting room, none at all.
I have tried simply interviewing doctors, but that didn't work...they must be trained in the same way to treat women aggressively and force them into these exams and tests.
They must be taught that we have no right to choose regardless of the purpose of our visit.
Remember we're talking about VERY intimate exams, very intimate...nothing more intimate as far as I'm concerned...being forced, intimidated and harassed to submit causes psychological damage and if you submit, you feel like you've been sexually assaulted...it bruises your soul.
I probably have a phobia at this stage, but I see many women suffering at the hands of doctors thanks to the total acceptance by the profession that this is an acceptable, even preferred way of treating their female patients.
The doctor who said cervical cancer is a greater risk than breast cancer should be reported...that is a lie...breast cancer is far more common than cervical cancer....just another way of intimidating the patient.
Men are supposed to avoid doctors...yet I wonder how they'd cope if they were forced to have an instrument and fingers inserted into their penis whenever they visited the doctor for anything...a scraping taken and then often followed by a sample being cut out of your penis...only to be told everything is fine...it wasn't cancer after all, the test was incorrect.
Every visit, the same thing...and the constant threat of facing more biopsies.
I know so many women who live that way.
I think men would have changed things very quickly.
I'm not sure why we can't change things...perhaps because it's now established practice and women have been conditioned to think this gross indignity is part of being a responsible woman...perhaps it's because so many of us are forced to see doctors for gyn problems, birth control, pregnancy and menopause...they know many women HAVE to see them.
They therefore have the power.
It's very depressing...fortunately I'm a very healthy person and don't need doctors in my life.
The damage caused by the few I've seen in my life will last a lifetime.
No human being alive has the right to take my rights away as to who has access and does what to my body...a white coat does not change any of that....

Anonymous said...

Gilly,

I don't think my doc was exactly saying cervical cancer is a far greater risk for women than breast cancer. I think was that for a woman my age, it should be of greater concern. I guess the implication being that we youngsters are all a bunch of bed-hoppers and older women are not. And also that breast cancer is an old-lady disease, which it isn't always. I also must note that when I mentioned to her I was scared because my grandmother was diagnosed with breast cancer seven years ago, she dismissed it as having to do with my grandmother's age at diagnosis (age 79) and not the HRT she had been put on after she had a hysterectomy while in her 40s. I believe she was on HRT for quite a long time, possibly up to her diagnosis, and one of her Drs. pointed to it as a likely cause. She had surgery and is now on Arimidex for the rest of her life and has had no problems in that regard since.

But anyhow, I do think what the Dr. and the nurse said to me were meant to somewhat scare me into having that exam. I don't appreciate that, esp. since I was already a nervous, emotional wreck thinking I had something else wrong with me. Why heap more anxiety onto a patient who obviously doesn't need it? I just don't understand. :(

Anonymous said...

I don't want this to sound insensitive but I'm glad I read a few of the comments here (I'm a guy).

Up till now I believed only men got treated so unfair and disrespectfully in the medical world. I guess there is a little more balance than I thought. Men definitely have their share of ridiculous and unethical problems (like worthless hernia checks by two women in order to play school sports, ALWAYS female nurses for intimate procedures, etc), but I understand now that men aren't alone as far as unethical treatment. I'm a lifetime bachelor so I had never heard of the problems with birth control.

I sympathize with you now more than I used to. Thanks for sharing your stories. By the way anon, I've got you beat. I'm a 37 year old virgin.

Nathan said...

We have problems with unethical doctors as well.
Unfortunately the government pays our doctors a large bonus when they screen 80% of their patients.
My mother-in-law had a complete hysterectomy for fibroids (no cancer) six years ago.
She was pressured to keep having smears and finally contacted the Health Dpt and reported the doctor to the Medical Board.
It seems some doctors will screen anyone to get to their target.
Highly unethical and I would imagine, possibly an assault to put a woman through this sort of exam when she is no risk.
I read that 10 million US women in this position are still being tested....many years after doctors were told in that country NOT to test these women.
This testing is out of hand and something needs to be done to stop this abuse.
If you argue that you're checking for vaginal cancer, then start lining up men for penile cancer checks...it's even rarer than penile cancer.
Screening has led to lots of unethical and possibly illegal conduct.
http://jama.ama-assn.org/cgi/content/short/291/24/2990

Anonymous said...

gilly, as Nathan said, men have their share of indignaties as well. From those cited such as hernia exams for sports and always having female assistants to DRE's and the assoicated biopsies that they often trigger.

I think the real crime with the pelvic exams is the pressure they put on women and what seems to be blackmail. If they are witholding birth control to force pelvic exams and there is no real valid reason, that is just plain wrong, that is coersion. I think it comes from a combination of things, it could be profit driven as suggested, but I also think more universal issues are at play here. One the paternal-maternaistic view of medicine that they know best...regardless of what we think or want...they know best for us like it or not. That thing we have argued before, why do they think they have the right to exert their opinion over our right to self determination. And second, SOP, the medical community gets into these ruts where they follow established procedures without questioning them long after they have validity. Take the practice of forcing patients to be nude under those stupid gowns for things like eye surgery, shoulder or wrist surgery. They argue safety...but take the odds of a patient having complications X the odds that they won't be able to get a vien up top so they have to go to the femeral X the odds that the time it takes to move or remove shorts will have an significant effect on the outcome...now compare that to the odds that a caregiver will be come in contact with a patient with mersa or that a provider is running on to little sleep, had a fight with a spouse or is some other way distracted...yet patients are still forced to be nude even though it causes them stress, makes the experience more negative than it has to be...they really can't defend it rationally..but they defend it none the less..becasue..thats they way they have always done it...anyway you slice it, its wrong....alan

Harriet said...

American women have been brainwashed in the main to believe all these checks are essential to their health.
Many don't even question the need...
I have always considered them totally unnecessary.
It's sad so many women don't even feel they can consider their risk profiles and decide for themselves.

I was reading this article on another site and it quoted a number of gynecologists criticizing women who prefer female doctors.
I know this discussion came from the ObGyn.com website as I saw it there a while ago.
The most staggering post is made by a female doctor (maybe trying to win approval of and acceptance by her male colleagues) who says women who've been sexually assaulted should NOT be accommodated otherwise they'll never become "desensitized" or get over it...
I thought that was the most callous, cold and insensitive thing I've ever read...
IMO she's a disgrace to the profession and has let women down badly...she's as bad if not worse than the most paternalistic of male doctors on the site.
There are many great female doctors but sadly, some have "identified" with the worst of the male doctors as far as attitudes go, perhaps, to survive in medical school and during training and are now very hard and cold people.
Having worked with the victims of sexual assault...it's just devastating to read these sorts of comments.
http://blog.iblamethepatriarchy.com/2006/02/18/gyno-knows-best/

YC said...

What I don't understand...is how these doctors think THEY even have a right to comment?
I choose my doctors...I CHOOSE...it has absolutely nothing to do with them.
I have never explained my preference for doctors...why should I?
I favor a few businesses and have seen the same dentist for 20 years...no one asks me to explain or criticizes my choice.
It makes me think that these doctors are arrogant and out of touch...
I wonder how they would react if their preferences were criticized...
I think this may be a reaction to the fact that once women had no choice and some would say, suffered badly as a result.
I read a horrifying book recently called the History of Gynecology...like putting a bunch of weasels in charge of the chicken coop.
I have seen same gender doctors all my life.
No one has ever challenged me...or disregarded my preference.
I would never allow that to happen...
I'd simply leave and find another clinic...there are plenty around...anyone who disregarded my preference would simply find themselves without me as a patient.

Anonymous said...

The problem we share as patients male and female is the lack of recognition by provdiers we have the right to choose not only the gender of our provider but what sort of risk we are willing to assume. Females have the right to decide whether they are willing to accept the risk if there is any to get birth control with or without a pelvic exam. The general concensous of women here is they do not need them. Likewise, every year young males are subject to hernia exams often by female Dr's or NP's becasue.......how many of us know of a single kid that was determined to have a hernia from these exams...the common thread, the medical has always done it this way...they don't quetion these practices even when the statistics don't back them....alan

Phil said...

My wife and I were fortunate enough to live in Scandanavia for 7 years.
During that time we got an opportunity to compare health systems.
We see clearly now that doctors play too big a part in our lives.
We don't need this level of intervention...it's pointless, time-consuming, possibly embarrassing or uncomfortable..and so often leads to further exams and referrals.
The hernia checks are unnecessary, testicular exams are not recommended elsewhere, no prostate checking before 50 and then only a blood test, no mammograms before 50, no pap smears before 30 and then every 5 years until 50 or so...(low risk women often don't have them at all)
No skin checks unless you find something and want it checked, no routine colonoscopies unless you have family history, no clinical breast exams before 40 or 45...
No routine pelvic or rectal exams ever....
It really surprised us...it took us a while, but we're now more comfortable following a foreign agenda and taking a more relaxed approach...
I think these excesses cause a lot of the worry regarding privacy and modesty.
When our lives become medically controlled, we sort of lose control of our bodies.
I don't find that notion reassuring...it intrudes into our lives and causes unwelcome issues and problems.
Check the recommendations overseas before following ours...they're fairly uniform and we stand out...
Depending on your point of view, we're either thorough or excessive.
We're had some issues with our doctor since we got back...but we've made up our minds. Our doctors don't like patients making decisions outside their recommendations even when you have sound evidence and reasons.
The list of recommended exams and tests now we're 50 is very long...we won't be following it...it's just too much...we'll follow a much shorter list in accordance with the recommendations of the majority of the world's doctors.
That's good enough for us.

Anonymous said...

Phil,

It's interesting how things are so different elsewhere in the world than they are here.

I don't know how to explain it exactly, but it seems as though we're living in a culture of fear in the US. It's like we're being conditioned to be so afraid of anything and everything that we'll readily submit to whatever exam is available. Doesn't seem to be the right way to go about things. Why isn't there more emphasis on true disease prevention? As in lifestyle changes, dietary measures, not engaging in risky behaviors, etc. that we can all take to stay healthy?

Phil said...

I agree...
We're so often pressured into conforming and having every test under the sun EVERY year....yet we're probably a very unhealthy country overall...
Look at the problem we have with obesity in this country.
Obesity causes heart disease, cancer, diabetes and reduces the quality of your life.
I think with this obsessive checking of our bodies, we've lost site of overall health and well-being.
I now believe the focus is all wrong in this country.
Also, many of these exams are difficult for us...why have them more than absolutely necessary?
Particularly, when excessive testing is likely to hurt us.
There were so many examples...things we'd been told were essential, are not even done overseas.
My wife was really upset by this news to start with...she'd been put through so many upsetting exams and treatment from her teens and it's clear it was all unnecessary. At this point she's just enjoying the freedom and feels like she's in control of her body for the first time.
She's no longer motivated to comply out of fear.
I feel the same way, but to a lesser degree.
I think women in this country feel the negative effect of all this testing and examining from an early age.
A life with fewer of these intrusions is very welcome...and when you know it's actually better for your health that way...you have true peace of mind.

Anonymous said...

"A life with fewer of these intrusions is very welcome...and when you know it's actually better for your health that way...you have true peace of mind."

Peace of mind should go a long way toward good health, shouldn't it? I'm not a doctor, but I would think all of the fear, anxiety, worry, stress, etc. generated by these tests and the scare tactics employed by some medical professionals to get patients to submit would be very detrimental to a person's mental and physical well-being.

Phil said...

I totally agree with you.
My wife is sorry she didn't have access to this information when she was younger...a lot of this preventative medicine that's aimed at us can be very traumatic and harmful.
She went through hell when a doctor insisted on a breast exam when she was 18 and it ended in several breast biopsies...no cancer, just normal tissue.
She now finds that this is the very reason foreign doctors do NOT recommend CBE's for women under 40....
She would have been spared all of that if she had lived in another country...not to mention all the extra tests and referrals that flow from the annual physical.
It seems the focus in this country is on catching cancer, even rare cancers and the health and welfare of healthy people is seriously compromised in the chase.
It's a very unhealthy way to live...in my opinion.

Lewis R said...

I'm with Phil...
I never even thought about it until my new wife complained to me about doctors being very bossy in this country and treating women like ignorant fools.
Sorry?
She told me about all the things that doctors insist upon before giving you birth control.
My wife is Dutch and had never been asked to have these things in her country.
I went along with her and asked the Dr to respect her wishes...she preferred not to have these things and given doctors in the Netherlands don't require these things...what is so different here?
Why do our doctors feel these things are so important they can refuse to give a woman birth control pills until she agrees to the exams?
The doctor basically said...my way or go elsewhere.
My wife spent about 2 weeks calling around and kept hitting brick walls.
We eventually found our way to Planned Parenthood, who follow the international standard...blood pressure check and history.
I had no idea our medical profession made such unreasonable demands and are arrogant enough to think they have the right to refuse any woman birth control.
I must say I've had little to do with our doctors over the years.
I think it's time for a shake-up...stop with unreasonable demands and adopt and follow international guidelines.
No other country in the world puts these hurdles in front of women.
No wonder we have so many unplanned pregnancies and abortions.

Joel Sherman said...

Copied from the mass media thread:

PL said...

Women are never "offered" screening...it's demanded or forced on us.
My closest friend was forced to have screening to get birth control. Nothing new there...
She received no information at all and it wasn't her decision to have the test....if she didn't agree to a smear, she wasn't going to get the BCP.
This is a widespread thing in this country...no smear = no birth control.
We're denied the most basic of human needs (birth control)and often even totally unrelated medications, until we agree to a smear.
It's a fact...
Cancer screening has never been "offered" to us.

She was sent for a cervical biopsy after receiving an "abnormal" smear. The experience damaged her in every way.
She may now have trouble getting pregnant and will certainly need medical help to see a pregnancy to full term. She is also having trouble with anxiety and depression. Medical things are hard for her and now it looks like she'll need the most intimate and embarrassing medical help in the future.

It turned out the test was just wrong...she WAS a healthy young woman.
Her lawyer tells her she has a very strong case.
His research has revealed that one in every 13 smears in women under 25 leads to colposcopy.
Cancer in this age group is very rare.
He has found that many countries don't screen women under 25 or 30 to protect young women from harm.
This is a fact and well documented in medical journals.

He believes screening must always be the woman's choice and the risks must be clearly spelt out...and that women under 30 must have the very high risks clearly outlined to them.
That has never happened with cervical or breast screening.
Doctors have gotten away with just pushing us into screening and we live with the risk and damage.

Many women just accept this sort of treatment. My friend only discovered the truth because she wanted to avoid a repeat of her first experience....she went on a fact-finding mission.
Her attorney has found a website pointing out this clinic "requires" smears before prescribing the BCP (and almost all other clinic's have the same requirements)...and evidence to show this test can never be demanded...only "offered" - it should never be a requirement for birth control or anything else. Doctors must also obtain informed consent...
The doctor's conduct, he believes, amounts to coercion and an unlawful acceptance of risk on the patient's behalf & without the patient's knowledge or consent.
I'm surprised this doesn't happen more often...most women just don't get to the truth.
We're told it's for our own good, and we believe them.

Hopefully, more cases like this will force doctors to release all the information to patients and respect our decision to be screened or not and finally end the unethical "requirements" for birth control AND doctor's refusing any treatment for any other totally unrelated thing until we agree to a smear. (Yes, that happens every day)
It's hard to believe that this has been going on for so long.
How could any ethical doctor have thought this was an acceptable way to treat women?
August 27, 2009 12:35 AM

Joel Sherman said...

Copied from the mass media thread:

Jan said...

I'm so delighted to read the last post although terribly sorry to hear about your friend.
I hope and pray a class action is just around the corner.
I hope there are serious consequences for the way women have been treated in the States.
I think there is a tidal wave of women that could follow your friend.
I hope the "controlling" of women and their reign of abuse is almost over...
I now live safely in Australia and have been out of their clutches for 5 years now.
I well remember contacting clinic after clinic trying to get birth control without all the unnecessary, unrelated and unethical "requirements".
I worry about all the women I left behind that are still trying to live with this "system".
August 27, 2009 11:28 AM

Jo said...

I went to a Dutch doctor like a dutiful American woman ready for another loathsome annual gyn exam.
I've always hated these exams and actually vomit a few times before the appointment.
The Dutch doctor just looked at me and wondered why American women need this reassurance every year.
She said to trust my body...we don't need these exams.
These exams can hurt us.
I was stunned and overjoyed at the same time.
We just don't question what has always been and what surrounds us.
Many of my friends still won't accept this doctor's advice, they are so afraid after listening to our doctors doom and gloom speeches.
The Dutch Dr who looks after exchange students also said she knew that a lot of the American girls had already had treatment for abnormal smears.
She told me all of this was very unfortunate and a likely consequence when you screen young women.
She said none of those girls would have been screened in Amsterdam and none would have had treatment already.
She said cancer in the very young was so rare...that all of this treatment was almost certainly for things that would not have turned into cancer.
She couldn't understand why our doctors take this approach.
She had cared for a 18 year old American girl with an infection after a biopsy (in the States) the month before...she said it upset her to see a beautiful young girl put through so much for no benefit at all and now likely to have problems in the future.
I go to Planned Parenthood...I might follow the Dutch program when I'm 30...or I might not...what a change in attitude? What happened to the fear?
I now fear our doctors far more than this rare cancer.
Even PP pressure you after a while. If you keep saying no and make a fuss if need be, you get your Pills.

Wendy said...

I have noticed that as well...
I work for a Dutch travel company and we have American & British working in the office.
Women tend to talk about embarrassing things looking for advice and support.
I noticed almost all the American women have had treatment for pre-cancer. (all in their 20's)
Three have had fairly major treatments requiring a general and overnight stay in hospital.
Many of us find this unusual...the Dutch women roughly the same age haven't even started having screening and one older woman (late 30's) is very low risk and has no screening.
The US women stand out...
I assumed the States must have lots more cancer...but when one of the women told me she was a virgin and I know you need to have caught a sexually transmitted disease to get this cancer...I became totally confused and a bit afraid.
I spoke to a local doctor about all of this.
I was told that Australia and the States start testing women when they're very young.
Young women produce lots of results that suggest something is wrong...but they're normal for that age. She said these women should not have been tested at all.
Virgins should never be tested...she was aware some American doctors test virgins when they turn 21 and she said that was totally unnecessary and risky as it could lead to treatment when there was no possibility of disease.
She felt strongly that women under 30 should not be tested and then only every 5 years...that way you catch disease but massively reduce the number of women having further treatment.
Most of this treatment is unnecessary.
I'm relieved to have this knowledge...the UK tests from 25 and then 3 yearly.
We recently rejected a call to drop the screening age to 20.
Listening to the US girls it's a stark reminder that it's not always the case that our health policy makers have our best interests at heart.
It seems the emphasis in some countries is to test with no thought for the damage you may cause...
I don't agree with that at all.
Doctors rarely mention that if you're both virgins, you don't need testing at all.
That was never mentioned to me (except by the Dutch Dr)...the risk of this cancer is low anyway...very low for low risk women and apparently for someone like me (both virgins) testing is not recommended at all.(again because you risk treatment for an incorrect result that suggests pre-cancer...when there is most unlikely to be any disease present.

Joel Sherman said...

A related topic has been brought up by Jess on the informed consent thread concerning screening for breast cancer.
Here is a link to a Dr Baum from the UK who has done much research in the area and is against routine screening. I personally am not familiar enough with the data to take a stand. My wife gets annual screening. But the controversy is more substantial than I was aware of and many of you may be interested.

Tanya K said...

I think cervical screening is the best example of a successful brainwashing campaign.
I was reading some comments made about an article reporting a pilot program where women can buy the BCP over the counter at a pharmacy in New York.
Some doctors believe the medical barriers are responsible for many unplanned pregnancies and that these barriers are unnecessary, even unethical.
The comments, mainly by women...were sadly, predictable...
"Oh, No..these women won't have paps"..."if women aren't made to have smears, they won't have them"..."if women have to see a doctor for pills, they'll be forced to have paps"...

Having studied medical ethics at University, it highlighted the effectiveness of the campaign.
The paternalistic attitudes...(some might say unethical, some might say unlawful) in relation to cervical screening have been transferred into women's minds as an entirely appropriate way for women to be treated and nothing is open for discussion.
It seems that discussion is over before it started...

No one acknowledged that it's a woman's right to access reliable birth control without having cancer screening forced on her...no one mentioned informed consent or coercion, no one mentioned that birth control is totally unrelated to cancer screening and should not be made a compulsory part of a birth control consultation, no one mentioned the risks of testing, no one mentioned civil rights or women's rights.
The attitude (in the main) was that women should not have easy access to Pills or they may choose NOT to have screening and that was a bad thing.
I wonder how far they'd take that...holding a woman down against her will...making it a pre-requisite for everything...treatment for the flu, a requirement to enrol in college or play sport...compulsory testing by law.

I'm not surprised though...these women have accepted all they've read and been told without question.
They simply don't know the whole story...they have no clue there is another side to the story or lots below the surface.
The risk of this cancer is unknown to them or they perceive it as a hugh threat...no screening almost certainly means death from this cancer...any downside would be immediately dismissed as necessary to avoid this deadly threat.
They've only been told half the story and a biased summary at that...
You even find virgins and women in lifetime mutually monogamous relationships being tested year after year for fear of dying of this cancer...when the risks of testing them are FAR greater than the risk of this cancer.
IMO, their perceptions bear no resemblance to the facts.
Some women have no idea what the test is for...ovarian cancer...or it's a "health thing".
I think that's what doctors wanted...to keep women afraid and complaint, but largely ignorant...not to look at this test too closely or ask too many questions...just do as you're told.
It should become an article of faith and that's why some women are threatened and outraged if anyone dares to question cervical screening.
This is one of the main reasons I chose a method of birth control that did not rely on a doctor's script.
I have a need to know and find answers...only one person will decide whether I have testing and that is not my Dr.
It's my decision.
My friend said to me recently, as she lit up another cigarette, her third in that hour, "you'd be mad not to have pap smears, they're essential for your health".
Why?
"Ummm, they just are...my Dr said all women must have them or they stand a high chance of dying from cancer"."you're taking a massive risk"...(puffing happily on her cigarette)
Um, I beg to differ....
I say nothing...I'd be wasting my breath...it's an article of faith.

James said...

The real value of screening...a few lucky ones and a HUGE number of unlucky ones.
Success story...depends who you ask?
On cervical screening:
http://www.bmj.com/cgi/content/full/326/7395/901?ijkey=kndK1dePPBERM
I think there are serious risks with mammograms as well.
ANNUAL screening seems to involve the most risk...you're getting more radiation and damage to breast tissue - most countries offer screening from age 50 and then 2 or 3 yearly.
It seems a common thing in the States...people having screening when they're no or very low risk, too young or having it too often or all three...and that carries serious risks for your health.

Vonnie said...

I read a really informative article on mammograms recently.
It may be of interest to some of you.
It answered a lot of my questions.
I find that I have less fear when I'm armed with the facts. We tend to over-estimate the risk of getting these cancers.
http://www.healthbeatblog.com/2009/04/
mammography-screening-a-double-edged-sword.html

Nancy Page said...

This appeared in the LA Times recently.
It's a great article on mammograms.
I've concluded the safest approach is to have screening later and less often...perhaps 3 or 5 yearly from 50.
It's clear the US annual screening recommendation from 40 may not be the best approach in light of new evidence.
http://www.latimes.com/features/health/la-he-breast-overdiagnosis17-2009aug17,0,5184447.story

Jane K said...

This is the article that appeared in the British Medical Journal this year that threw a weasel in the hen house.
http://www.bmj.com/cgi/
content/full/338/jan27_2/b86?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=
&fulltext=%22Mammograms%22&searchid=1&FIRSTINDEX=0&sortspec=date&
resourcetype=HWCIT
I have had concerns about all of this cancer screening for years.
Why fix it, if it isn't broken?
I guess I just don't like looking for trouble and that's not to say I'm sticking my head in the sand.
It just always seemed squashing my breasts and sending radiation through them every year was not a great thing to do for my health.
Seems I may have been right and I didn't even go to medical school!

Joel Sherman said...

From mass media thread: Part 1

Tim said...

The emphasis on screening and preventative exams and tests has added significantly to modesty and privacy issues....and perhaps, is dangerous to our mental and physical well-being.
It seems we should do away with a lot of this testing.

Quote:MER
"Hence I believe one of the reasons for the extensive promotion of screening tests/exams of questionable value to the targeted population. Indeed, recent studies have shown that indiscriminate testing often leads to more harm than good."

Totally agree with this...if you look at the recommended tests for Americans at any age and compare it to any other developed country, we stand out.
In every case, we start testing years earlier than other countries, we test more often and test into old age.
Over-testing can cause major problems...more is not necessarily better.
Our women have VASTLY more pap smears than other women....and we are the only country in the world to test virgins.
We have the highest rates of cervical biopsies in the world...but we don't have the lowest rates of cervical cancer.
Why not, when we test to this degree?
It clearly isn't the right strategy and puts lots of healthy women through biopsies.
I'm sure these exams are very difficult for women anyway...so why put a woman through 50 or 60 pap smears when it may actually be more effective and much safer for her health to settle for 5 or so tests?
(I followed a link from one of the posts to the Finnish program which is considered the most effective in the world and they don't test virgins or women under 30, test 5 yearly and stop at 50, 55 or 60....)
Our recommendations seems shockingly excessive with no regard for women's privacy or what is actually in the best interests of their health.
We also REALLY pressure women in this country to have this testing.
I suspect the only reason they can over-screen our women is because they need birth control and our doctors control that totally...so, our women can't avoid this over-screening.
No pap smear and doctors can refuse to give you birth control.
So, who benefits from all this testing, certainly not our women.

Mammograms start at 40 and are annual.
Other countries it's 50 and every 2-3 years.
We send lots of women for breast biopsies.
It now seems there are increased risks having mammograms before age 50 or 55 and more often than 2-3 yearly.
My sister's birth control script was held until she had her first mammogram at age 40.
Again...doctors force screening on women because they control birth control.
If doctors can't behave responsibly and ethically, perhaps our women should be able to access birth control through pharmacies. (for the sake of their health!)

Joel Sherman said...

Part 2 of Tim

Prostate screening...from age 50 in other countries.
Here it's years earlier...
My Dr recommended I start prostate screening recently, but at 35, I'm not interested...
Once again, lots of prostate biopsies.
Add up the cost in dollars of all this extra work.

We don't have less cancer as a result...we have very high rates of treatment for false positives and I guess more people are left with health problems as biopsies all have risks.

We're put through more...for no benefit...in fact, we risk our health every time we follow an American recommendation.

Even routine colonoscopies...many countries don't recommend them unless there is family history and if so, from 50 and 5 yearly.
Other people....no testing
Here most people start having colonoscopies years before age 50...my Dr recommends them biannually from age 40.

This MUST be about money...
What other explanation is there?
Doctors must know the recommendations in other countries and that over-testing just leads to health problems.(& privacy concerns)
I can't believe all our doctors and medical societies are that ignorant and out of touch...
I had a vasectomy last year so my wife could avoid this over-testing.
Now that she doesn't need birth control, she's finally free to refuse any test.
August 30, 2009 7:20 PM

Joel Sherman said...

Tim said: This MUST be about money...

Well that's much too strong and simple. Money is a part of every decision in ours and most societies. Nobody pushes tests that they'll lose money on. Organized screening programs have to turn a profit for the institution sponsoring them, but it may be a profit in secondary follow-ups and further procedures needed.
But in this country especially when it comes to the physicians' role defensive medicine is a huge part of the equation. Missed diagnoses can result in huge lawsuits. It is often easier to screen to prevent lawsuits. As I said in all this talk of health reform, no one is talking about malpractice reform. Routine malpractice (that is where no intent to harm was present) should be treated similarly to workers comp cases and our present legal lottery abolished.
Realize also that most tests are recommended before large scale follow up can provide evidence based recommendations. That happens much later. When the data is available, recommendations do change as is slowly happening for pap smears.
A few of Tim's facts I believe are wrong. Routine prostate testing is for men over 50. Routine screening colonoscopies are recommended only every 10 years.
August 30, 2009 8:12 PM

Joel Sherman said...

John has left a new comment on your post "The Mass Media's Treatment of Patient Privacy":

Actually this over-testing of our wives leads to colposcopy.
I don't know how much you know about this procedure...but my wife said it was the most degrading and traumatic experience of her life.
It now seems clear she was led down that path by over-testing.
The more tests...the more likely you'll have a false positive.

This medical mandated over-testing is harmful to women.
My wife won't have any more tests...so this over-testing actually ends up driving many women away from testing altogether.
We may think it doesn't affect us...it does.
I hated to see my wife go through this procedure...even with an all-female team, she was badly shaken by the treatment.
As a result of this over-testing and unnecessary colposcopies...I think more men have vasectomies.
Doctors in this country are the only ones in the world who withhold birth control until women meet their demands...smears, mammograms or even totally unrelated meds.
They use their power to control women.

This has a negative affect on our wives and our marriages...rationing pills to make them go further, dropping back to condoms, the emotional stuff that accompanies these frequent tests, exams and procedures, rising resentment, sexual problems.
I agreed to have a vasectomy at age 33, many years before I was ready.
It was the only way to spare my wife and protect her health and rights.
My wife believes her health was damaged by this compulsory testing.
I agree with her...
We need to stop doctors controlling and harming our women.

The facts are clear...women should be free to refuse these tests and we should not be testing so often and greatly increasing the risk of further unnecessary procedures.



Posted by John to Medical Privacy, A Patient Oriented Discussion at August 30, 2009 8:18 PM

Anonymous said...

The only way around it is to use condoms, have a vasectomy or use HOPE at Planned Parenthood.
I have to travel to use HOPE but I think its worth it.
I think doctors holding scripts has been a problem for lots of years but nothing changes.
People say it's illegal, they can't do it but they keep doing it and nothing changes.
What will it take to stop doctors holding scripts until you have these exams?

Screening gone mad said...

We test teenagers, virgins, far too often and even screen women with no cervix.
Over 11 million women who are at no risk for this cancer are still being tested.
That is just how ridiculous the situation is in this country.
Checking for cervical cancer...when women don't even have a cervix.
Why isn't this an assault or professional misconduct?
It means doctors just don't care who they're testing, as long as they're testing.
This is a 2001 article but it still goes on...I saw a similar report last month but can't find it at the moment.
http://articles.latimes.com/2001/jul/30/health/he-28161

terri said...

The guidelines for pap smears changed a few years back.
I've found most doctors have disregarded these changes and still demand annual smears.
My doctor said that if they move from annual smears, women won't come in for their annual pelvic.
Given women in other countries don't have routine pelvic's at all...this seems very unfair.
I disagree with this attitude...and if you need BCPs, you don't have a choice, you can't follow the new guidelines.
It does make me angry...
I even took in cuttings from the paper to show my Dr.
Changing guidelines has zero effect if doctors are free to disregard them and continue to force us to have smears every year.
http://www.thefreelibrary.com/Low-risk+women+should+not+be+over-screened+for+cervical+cancer.-a0156361252

Anonymous said...

I went off birth control 6 years ago to get away from annual smears and gyn exams.
My boyfriend used condoms for a while and then we decided to break up.
I won't use birth control that requires a doctor's visit in the future.
Condoms might reduce a man's pleasure but smears, gyn exams and biopsies reduce my pleasure.
I'm putting myself first from now on.
I've sent emails to Finland and Amsterdam to get information about their testing schedules. (after reading about these countries on this and other blogs)
There doctors seem professional and have put women's health first...
I'm not sure what our doctors are doing...but it's unacceptable to me.
The demanding of exams and tests before you get birth control leaves me feeling powerless and manipulated.
All of my friends who still want birth control are locked into yearly smears and most have had follow-up treatment.
The risk of follow-up treatment seems very high with yearly testing.
I don't think birth control is worth it...when we lose control of our lives, health and bodies.

Anonymous said...

To John,
You're not alone.
I had a vasectomy at 31...
My wife went off birth control and we used condoms for 3 years.
We got sick of them and worried about their failure rate.
The snip seemed the easiest way, given our system.
Women are really put through the works to get birth control.
I wonder how many men have had early snips because of these "requirements" for birth control pills.
This must result in lots of unplanned babies, abortions and men having early sterilization. (and strained relationships)

Anonymous said...

Your women are advised to have breast screening annually from age 40...
I wonder how many are aware of this research.

"Shouldn’t women aged 40–49 years know that, 3 years after screening starts, their chance of death from breast cancer is more than double that for unscreened control women (1)? Shouldn’t they be informed that it will take 16 years after they start screening to reduce their chance of death from breast cancer by a mere 9% (7)? Ironically, the twofold increased risk of death from breast cancer in the third year after initiating screening is statistically significant (rate ratio = 2.4, 95% confidence interval = 1.1 to 5.4) but has been dismissed as chance, whereas the 9% decreased risk of death from breast cancer 16 years after initiating screening is statistically insignificant but fuels enthusiasm for screening" (7).
Taken from: http://jnci/oxfordjournals.
org/cgi/content/full/95/
20/1508

I'm an Australian woman who doesn't participate in cancer screening.
I've yet to consider bowel cancer screening, but at this point would never accept a doctor's word that it's a good idea.

I'm dismayed at the information that the medical profession chose to withhold or ignore....
Every day more and more women (and men) have screening without the first idea of the risks to their health.
I think we all need to be very careful with all this testing.
Even when there is clear evidence of harm and a slight adjustment of the screening program would reduce those risks, the profession refuse to even consider a review.
When I look at screening, my first reaction is, "now, what aren't they telling us?"

Anonymous said...

I may be straying somewhat from the topic here, but this discussion has gotten me to thinking about something else that bothers me where women's privacy and dignity are concerned. Every once in awhile, I will run across one of those documentary-style shows that follows an expectant couple through the birth of their child. One thing that has always bothered me is the way the laboring mother is made to position herself.

In nearly every one of those cases, the mother is lying flat on her back with her legs either pulled back/held back by her husband and a nurse or placed in some sort of leg-rest contraption. Not only does it look uncomfortable -- downright painful, even -- but it also puts her in an exposed, vulnerable position much like that of the gyn exam. It doesn't seem her comfort or privacy are being respected at all. I'm not a doctor and I've yet to give birth to any children, but what I have seen from these documentary type shows bothers me and makes me think there is something wrong with the way things are done. I would think allowing the mother to labor/give birth in whatever position she is most comfortable would be the best thing, as well as affording her some measure of dignity. Speaking only for myself, I certainly don't want to be strapped down to some bed and have my legs held back like that with people standing all around viewing my private areas and telling me to push, push, push. I am wondering if any of the moms or dads posting on here have any thoughts on this issue. Maybe giving birth is so painful that privacy/dignity isn't even a concern, but that is something that came to mind when I was reading through this discussion. Any thoughts?

-- Susanne

Stephanie K said...

Susanne,
I totally agree...
My cousin is a midwife and she tells me women are more comfortable squatting...instead of working against gravity.

If you look at the yearly gyn exams that US women go through every year...same thing, stirrups, paper gowns or sheet, being asked to undress before the doctor arrives - all designed for the doctor's benefit...with no regard for the feelings of the woman.
This is unique to the States, as far as I'm aware...
It certainly doesn't happen in the UK or Australia...stirrups are used in surgery only and these exams are not recommended at all. (not even mentioned)

My sister gave birth in a private hospital...she gave birth in her own private room with her female doctor and midwife in attendance.
It was a private affair and she delivered in a squatting position.
She was free to deliver in any way. (the hospital does not do water births)

I think private birth is possible if you tour the birthing facility beforehand, ask other women about their experiences and make it clear to your Dr and the facility that you want a private birth.
Word up your partner/husband ahead of time as well.

Beware of large teaching hospitals and facilities that move you to birthing suites or theatres...they can be very public areas.

I think these documentaries probably use women who are unconcerned about privacy, if they're happy to have a filming crew in the room.
Some women even invite extended family into the room...my cousin told me one woman invited her father and FIL into the room & others.
Makes me shudder!
I certainly wouldn't want an audience in that situation...I'd feel more comfortable in as private a setting as possible, so I could concentrate on the birth.

I think women in the States face the toughest battle as far as privacy is concerned.
I'd hate to feel compelled to have annual gyn exams and face way more intimate exams, smears and mammograms than necessary...in fact, I think having too many is likely to be harmful.
I have an American friend..comparing my friend's experiences to mine, I'm very pleased I'm not living in the States.
I would hate that level of medical intrusion in my life.
I'm a healthy woman and I don't need my reproductive organs checked every year...it's scary in a way just how easily the profession can convince us that something is vitally important...when in fact, the opposite is true.
I must say I haven't had a real problem in that regard...I simply told my Dr that I didn't want smears...for me, its just too inaccurate a test when my risk of this cancer is so low.

You're all put through so much it must threaten your mental and physical health and certainly your quality of life.
It's an indication to me your doctors don't value your privacy and dignity at all.
I was shocked to read recently that one in three US women have had a hysterectomy...that's a HIGH figure!
I guess that's a likely consequence when you have such a high level of medical interference in your lives.
My US friend told me she doesn't fear cancer, she fears US doctors!

Joel Sherman said...

This link was posted on Bernstein. It is a very academic defense of a woman's right to contraception without undergoing a pelvic exam. It should be of interest to most of you.
It derives from a Harvard feminist law blog.

Melissa said...

Isn't it strange that routine pelvic exams and gyn exams only seem to happen in the States?
The feminist movement strong...and lots of impressive and successful women...yet these practices continue....women being forced to have such invasive and unnecessary exams.
I can't imagine being refused contraception.
A simple blood pressure check is all that's needed...
I would refuse to go through all of that and would speak to a lawyer...it can't be defended in any way.
Cancer screening is up to the individual woman.
Some doctors do pressure you, others may ask or recommend, but I've never been harassed about them and they certainly don't dominate every consultation.
If that happened, I'd change my Dr.
My Dr knows I won't have unreliable tests especially for a fairly rare cancer and when I'm low risk.
She accepted that and now it's never mentioned...
I was reading another forum and the US women were saying they dominate every consult and doctors refuse you all sorts of things unless you agree....
I'm amazed they can get away with that in the States.
It really surprises me.
It surprises me even more that all of this has been a problem for years, yet nothing has changed...
Here's hoping change is not far away.

helena said...

Actually...I've long been concerned about the dominating, controlling and disturbing presence of doctors in the lives of American women. (I'm not sure about men)
I first heard about all the routine annual gynaecological exams many years ago...
I then heard about all the women who've had hysterectomies.
All the extra tests and intimate exams.
I then read something that stopped me in my tracks.
Female children being subjected to vaginal exams at school.
I found an article about the practice...not the one I read a few years ago, but similar...

I didn't have any medical exams at school (no one did)...it was my parent's responsibility to take me to the Dr as required.
At no point did I have my genitals examined...they were never general exams...I saw the doctor for a cold or a sprained ankle.

I really think this obsession with extreme thoroughness causes enormous damage to women. (and girls)
I would have been deeply traumatized going through that sort of exam.
I think if we understand the need for an exam...we have bad pains for example, we're more accepting of the exam with the right doctor...but all of this "over the top" intimate examination is, in my opinion, total madness.
It seems to be unique to America.
I haven't heard of these excesses in other countries.
http://www.howtotutor.com/bel/June_1996.pdf

Joel Sherman said...

Helena, that's an interesting article, but several points are worth noting. The apparently mandatory exams the girls received were of external genitalia only. No internal exam was attempted. The exams were done by a woman with a nurse present. Exams of the external genitalia are part of routine pediatric recommendations I believe. In short, the exams were within medical guidelines. That's not to say they were needed. Few school districts today perform medical exams for any reason except sports physicals. Boys are routinely made to undergo external genital and hernia exams which are even more humiliating especially as women are usually present. The indication for doing this on a regular basis for either sex is not clear.
American medicine uses thoroughness as a gold standard which is not always appropriate and certainly not cost effective. But patients and parents should be given the option to refuse these exams.
In passing I also note that the article you reference is from a highly politicized newspaper which clearly has other agendas.

Anonymous said...

Doesn't the profession understand or care about the emotional distress caused by these exams in both men and women, boys and girls?
I've never heard of such a thing...genital exams as part of a pediatric exam!!
Kids don't have routine or annual exams, they just see the GP when there is a problem.
They would only see a specialist if they were referred for a specific problem.
We all see the Dr when the need arises...an annual general exam doesn't really start until middle age when you need blood tests and blood pressure checks.
I was reading about the annual exam for women and I haven't had an exam as comprehensive as that EVER...not even close.
It seems most of the trouble stems from these annual routine and VERY thorough exams.
It makes me wonder whether the discoveries made as a result of these checks are worth the upset they cause...
It seems that rather than wait for the patient to see the Dr for symptoms or because they're concerned about something, everyone is examined to check for something very few would have...
I assume these thorough annual exams must have low clinical value or debatable value anyway or our doctors would be recommending them as well.
I see a dermatologist for a skin condition.
After reading about these skin checks, I asked her about these annual checks...she simply said, "No, you don't need that...you have very few moles...if you notice anything new or anything changes, come and see me"...."and get your husband to check your back every month or so"...
I wonder if an American doctor would give that advice.
Does common sense have a place in medicine?
I just wonder whether the current approach is likely to cause more harm than good.
helena

Joel Sherman said...

Copied from the gender preferences thread:

Elise A said...

"Also you say that men routinely avoid health care more than women. I would say that because usually need to visit the doctor for birth control, we are forced to visit the doctor usually once a year. Otherwise I think you would find women are just as likely to want to avoid health care." (Quote:Anon)

I think this is true.
I have never relied on doctors for birth control because of their unreasonable demands.
I saw my friends blackmailed into distressing and unnecessary exams to get birth control.
Several felt they had to sell their bodies for birth control.
It caused all sorts of very negative emotions....bitterness, resentment, anger, unhappiness, disgust and depression.
It even broke up one relationship after my friend couldn't cope with any more personal intrusions after a demeaning, terrifying and painful cervical biopsy.

I explained to my boyfriend (at the time, now my husband of 18 years) what I'd be put through to get BC.
We both did our reading and emailed several medical societies overseas and found out very quickly their demands were totally unnecessary.

The routine gyn exam is totally unnecessary and screening is a matter for the woman...it can never be demanded was the message loud and clear from all the medical people we contacted around the world.
I'm a happy, healthy woman.
Most of my friends have had various and deeply distressing biopsies of numerous varieties and face these exams every year OR no BC.

I see a doctor now and then for general things....when you don't need them for BC, their power disappears.

I think there is a huge difference between having exams and procedures that are actually needed when you're unwell or YOU choose to have AND all sorts of extra things DEMANDED of you...many of which CAUSE health problems.
Whenever our doctors come out with further demands, I check the requirements overseas and usually find the opposite view or a greatly modified recommendation.
Our excessive and demanding approach is harmful.

Joel Sherman said...

Elise A Part 2:


One of my friends has just had her birth control held back until she has a mammogram. She's just turned 40...
There is now great concern about the risks of mammograms and in many countries that offer them from 50 (once again our doctors go over the top and make it 40 which greatly increases the risks)
only about 50-55% of women accept their invitation to screen.
How dare our doctors take away our right to consider the facts and risks and make up our own minds whether we wish to screen?
Who gives them the right to demand us to put our health on the line? The medical evidence is easy to find and very clear...the rest of the world's doctors have got the point...NOT before 50.
More and more doctors in England are warning women about the risks of mammograms at ANY age.
Surely, DEMANDING a mammogram OR you don't get BC, is unlawful.

Her doctor has simply said, no mammogram, no pills...so today she's going to Planned Parenthood to use their HOPE option.
Her doctor just lost a patient.
I had hoped she'd consult an attorney.
About ten years ago a pre-employment medical check called for a gyn exam.
I spoke to an attorney who sent a letter setting out the odds of a woman getting cervical or breast cancer and the odds of having biopsies for a false positive and the health risks.
Several references were attached.
It ended by saying, I would have the exam and test in exchange for their written confirmation that they would fully compensate me for any harm that may result from the exam. (In fact, I would have gone looking for another job if they'd insisted)
I was excused from that part of the physical (including the breast exam) and just had a general exam.

I hope more women refuse to be stood over like this and find ways of protecting their health, bodies and rights.
We must protect ourselves from the excesses and harmful demands of the medical profession in this country.
September 8, 2009 8:07 PM

Anonymous said...

I never really understood that birth control and female pelvic exams were unrelated. i assumed there was a possiblity that the pills contributed or increased problems. I assumed the ability to choose a female gyn made it acceptable. I have learned a lot about this issue from this thread. While it is a seperate issue and has some of its own issues, its not totally different from the larger issue that crosses gender lines, the medicl communities arrogance in deciding what risks we should and should not accept for ourselves as part of our right to self determination.....it reminds me of the hernia exams they put young males through for sports.....I have yet to know of a single case where one was found....hopefully some gyn's will break ranks and go against this practice and those loosing business will wise up...but then, there is always the probability that someone will not be screened and sue when they have problems......thus is our society...alan

Elise A said...

Alan, I'd be happy to sign a waiver/disclaimer or anything else. I offered a few times, but the doctors clearly felt by denying me BC, I'd be forced to do as I was told...
The patient is supposed to provide informed consent, so this conduct is unprofessional at the very least.

No country in the world denies birth control UNTIL women have cancer screening.
We were told over and over...it can be recommended, but it's the woman's decision.
She MUST give her informed consent because there are risks with the test.
We contacted Australia, the UK and numerous European countries...their doctors do not recommend routine pelvic exams for birth control or anything else.
Our doctors have made them mandatory..if they can't get us brainwashed to have them every year, then they use our need for BC to demand them.
It really is sickening...
The hernia exam is the same thing.
No exam = no sport.
Our doctors are excessive and go "over the top" and they end up negatively affecting lots of people...don't forget the emotional distress caused by all of these unnecessary exams.
It also affects our lives...my husband and I could not take advantage of reliable BC and the other poster chose not to play sport to avoid the mandatory hernia checks.
I'll bet hernia checks are not done overseas.

I know women who buy BC on the black market and overseas.
I was never happy to do that...
I don't like taking medication or hormones blind...there are so many brands and types, I wouldn't know where to start...
In some countries, you can buy BC over-the-counter and your questions can be directed to the pharmacist.
It shouldn't be necessary to go to these lengths to get BC.

Testicular self-exam or routine clinical exam, breast self exam, CBE before 40, routine pelvic exams or annual gyn exams, mammograms before 50 are NOT recommended overseas.
Cervical cancer screening varies from country to country, but none make it a requirement for BC.
We definitely test women far too early and far too often...and our women have LOTS more biopsies, with no benefit. We don't have less cancer than the rest of the world, just the highest numbers of biopsies, tests and exams.
This excessiveness affects men's health as well.
I don't take any notice of our doctors demands anymore...straight to my overseas contacts.
Ask a balanced professional doctor who has the best interests of his/her patients at heart.

Anonymous said...

we are currently hotly debating medical care costs......and yet we blindly accept this. now may be the time to get some legislative help. Perhaps if a few brave women would take this public through letters to the editor and in the newspapers etc it might get some traction. Its a shame we need to reduce this to financial issues as the reality is it appears to be blackmail and bullying women wherein the medical community feels they have the right to dictate what should be personal choice. who knows how it got this way, but unless the medical community can positively link the need for a pelvic exam to perscribing birth control, they are stepping over the line and assuming a role of making decisions that are not theirs to make...they can not tell someone if you don't quit smoking I won't give you birth control, if you don't loose 10 lbs I won't....this is little different and is a symptom of the bigger problem, the arrogance to decide for us.....alan

Joel Sherman said...

Copied to here.

Annette has left a new comment on your post "Gender Preferences in Healthcare":

I think doctors have worked out that women are fairly easy to manipulate and control.
I know many women who've bought the propaganda and submit every year.
I think if you challenge a doctor EVERY time they make unethical/unnecessary demands, things would change.
Doctors are not stupid...they KNOW they can't demand you have a mammogram and refuse you birth control until you do so....but if you allow them to do that...they got away with it and will keep doing it.
Doctors must be forced to obey the law and ethical codes of conduct.
I reported a doctor recently for refusing migraine medication until I had a pap smear.
I decided many years ago that all of this preventative medicine was not for me.
That is my choice...I prefer not to live like that and will take my chances with not just cervical and breast cancer...but every cancer.
I'm not having my brain scanned every year either although the focus for women has always been our reproductive organs.
The brain wouldn't interest them...the next thing will probably be mandatory vaginal ultrasound for ovarian cancer starting from age 16 or something equally nasty, extreme and unnecessary.
I take a novel approach and respond to symptoms.
The doctor was spoken to...but I get the impression these arrogant and bullying attitudes go straight to the top.
I think it will take legal action and media attention to stop the bullies that call themselves doctors.
I got my migraine medication...but the delay was inexcusable.
It's very poor that we have to go to these lengths to get the medication we need for REAL health problems.
I doubt this sort of thing would ever happen to a man.
Does it?
Are you refused Viagra or migraine medication until you have a digital rectal exam or a testicular exam?

Joel Sherman said...

This post copied to this thread:

Wendy H, Sydney has left a new comment on your post "Gender Preferences in Healthcare":

I was once told by an American doctor that he wouldn't want to be an American woman...that women suffer badly at the hands of the medical profession.
He said that if you have a health problem and have insurance, you'll receive the best medical care in the world.
Look at the world renowned Sloan-Kettering Centre for Cancer.
He did say that unfortunately healthy people get the same level of surveillance and intervention and he felt that had lots of negative outcomes and probably should be addressed.
He said that healthy people needed to monitor the advice they received and refuse any test or exam until they were satisfied of its benefits.
He did not approve of doctors requiring cancer screening before prescribing the Pill. He thought that practice was unethical and an abuse of the power vested in doctors.
He had never followed that practice, even though his colleagues felt he was putting his neck on the legal chopping block.
His view was that these exams and test are not needed for birth control and are supposed to be an option for the woman, but that doctors "imposing" these restrictions had now made them fearful of doing the right thing...and following the medical practice around the world and the recommendations of numerous medical bodies. He said those requirements were doctor-made at the Clinic level and were not recommendations from above...so doctors were "imposing" these exams and test against the recommendations and creating possible liability due to usual practice evidence.
In other words they'd created an unethical rod for their own backs.
He said when unnecessary exams and cancer screening that should be no more than an option become mandated...it's unfair on the patients and makes it difficult for doctors who want to do the ethical thing.
He didn't feel you could say these exams and tests were for the good of all women...in fact, they led to over-treatment in a high number of cases.
He felt testing virgins, very young women and every year showed common sense and balance had been forgotten in favour of blanket over-screening and over-treatment.
He thought it was a juggernaut that wouldn't easily be stopped with powerful drug companies, insurance companies, politics, pressure groups and lawyers all playing a part...
We met this Dr on an African safari in 2008.
I well remember our conversations about the US healthcare system.
I have an interest in women's health and used his comments at one of our meetings on cancer screening and informed consent.
Great blog...interesting reading!

Anonymous said...

Annette let me ask you, were you ever forced as a teen to line up with a bunch of classmates and have your vagina checked by a male nurse, if 92% of nurses were male would there be ramifications,,,,the issue isn't male or female its right or wrong, don't forget there are female doctors perpatrating this practice as well as male....we each have our own different issues...but I don't think being male or female has anything to do with why it is happening....alan

Joel Sherman said...

I just want to stress that gender wars are not productive to my way of thinking. Clearly men and women have different problems and perspectives on these issues and I want to hear them both.
The issue is not which gender has more problems or who is more discriminated against. This forum exists so that all of us can present and discuss the issues and hopefully suggest ways to improve the situation for all.

Anonymous said...

Interesting article from ABC News about the FDA panel approving the administration of the HPV vaccine for boys and young men. I wonder just how much press this will actually get and how many boys or young men will be pressured by their Drs. to get the vaccine and screening exams as so many women seem to have been. My guess is our young men in this country won't face near the pressure that women do. Thoughts, anyone?

http://abcnews.go.com/Health/Healthday/fda-panel-backs-giving-hpv-vaccine-gardasil-boys/story?id=8531585

TJN said...

Our doctors are under pressure to stop screening virgins and women under 21.
The fact we stand out by miles has attracted the attention of foreign doctors. Our women have heaps more smears and biopsies.
I found an article...not sure if it will link.
Its not the lengthy one I was reading recently...but covers the same thing.
If the link doesn't work...the article is by Ed Edelson, Teens may not benefit from pap tests.
Even if they change recommendations, it won't change anything.
They changed yearly testing to three yearly if you're 30 or older and have had three normal smears.
All of the doctors my friends see continue to do yearly testing and have totally disregarded the changed policy.
I guess they'll do the same thing with this change if it comes into effect...
They argue women won't go in for their yearly gyn physical if they don't need a smear.
The women who need birth control are caught anyway and if women still think they need annual gyn exams it looks like they'll still get a yearly smear.
The value of these gyn exams does seem debatable/dubious to say the least...
Perhaps, doctors are worried women will decide not to have the gyn exams at all and have fewer smears. That would mean a lot less work for them.
All of this does seem very unfair to women...almost a blatant disregard of recommendations to take advantage of women.
Very poor...

http://www.medicinenet.com/script/main/art.asp?articlekey=104176f
July 28

Joel Sherman said...

I have rejected a comment that continued the 'gender wars.'
Guys, there are several threads on this blog that present male issues and no women have challenged any of the views. I will extend to the ladies the same courtesy. That doesn't mean that all discussion of gender differences is out of place, but not if it is hostile.
If necessary, I can start a separate thread for those who want to argue which gender has the greater difficulties getting respectful care, but I don't think it would be profitable.

Adam said...

I don't think women are saying men have an easy time either...
They're just talking about their experiences...as females.
I can understand their outrage. (I share their outrage)
I have never been refused medication until I agreed to a DRE...but I know women face that problem all the time.
My wife was told no (unrelated) medication until she agreed to cervical screening.
We got the meds when we went to the UK on vacation.
I imagine if you wanted to avoid the hernia exam, you could just decide not to play sport. I grew up in South Africa and thankfully, that wasn't done there...I played sport for years and there were no exams.
Still an outrageous thing to have to do...miss out on your sport to avoid a genital exam.
Denying women birth control does strike me as the violation of a VERY basic right.
If women are unable to access birth control without these very intimate exams...it means more condom or foam use. (and very unreliable things like withdrawal)
Not everyone knows how to use condoms properly...and foams are not reliable...so more unplanned pregnancies.
There are lots of risks with pregnancy and childbirth.
Also, more men having vasectomies.
These highly unethical and surely it must also be illegal, compulsory requirements...affect men as well as women.
Our women feel manipulated, violated and abused...and fearful after going through the biopsy business. It is so common in this country...and no one seems to have cancer.
I'm not surprised to read these false alarms are caused by over-screening. I suspected there was an explanation because this cancer was never a hugh threat...its always been one of the less common ones.
As men, we are afffected by these "rules"...we have our problems with lack of male nurses...but personally, I believe the barriers used to manipulate women (and us)violates our civil rights.

I plan to send off a few letters...I have thought the situation unlawful and certainly, amounting to professional misconduct, for many years.
It's time something was done about this....
I had a vasectomy at 35...I couldn't allow them to keep treating the woman I loved like that...
I'm ashamed I didn't do something sooner.
Its time to declare war on our doctors and force them to treat our women with respect and dignity.

Anonymous said...

I understand and agree there is no little value in gender wars. My point here is I really don't think this issue is perpetrated on women because they are female. There have been numerous posts here that interject comments like "this would never happen to men" etc the most recent in regards as to whether men/boys will be pressured for the new vacine. The thing is we all are being pressured for different things due to our specific gender. The procedure at hand is pelvic exams for birth control. We agree on this thread, men and women it is wrong. But it isn't becasue you are female, the procedure is female specific, so obviously it only happens to females. Men/boys have their own version of this type of transgression i.e. hernia exams for sports, and then there common ones for both gender the why do I have to take my underwear off to have my ankle or shoulder surgery........its because the medical community for what ever reason has determined that this will be done and no one questions it, no one in the medical community challenges it because it has always been done that way. There was a post by a young female Dr. who was asking why she had to do hernia exams on male students when she didn't feel there was any valid reason for it, and it humiliated the boys. I read an article from an eye surgeon who stated that the practice of making a patient be naked for corena, lense implants, etc was completely ridiculous as there was no real medical reason and it was very stressful for the paitent......all of these things have the same common thread...its the medical world following practices that were established long ago without question, things change but they have not changed the procedure or the mentality that they know what is best for us medically so if we don't agree they have the right to impose it upon us. The issue of underwear or surgery shorts is a good one...well we have to incase you have complications from the anesthesia....so what are the odds of a major complication 1:500, 1:1000, wo multiply that by the odds it will require getting into a vien X the odds one in the neck or wrist won't do X the odds that moving the underwear or removing them will add enough time to cause an different outcome....yet, standard procedure is.... Whether that was for profit or what ever the reason....these have little to nothing to do with gender and everything to do with the world of medicine thinking they have the right to tell us what risks we can and can not accept...alan

Anonymous said...

Dr. Sherman,

Not sure where this will fit into the discussion on the women's privacy section, but there is another site I frequent on which posters discuss the issue of gyn exams and women's privacy. The thoughts of the posters there are much the same as those expressed here -- that these exams are humiliating, uncomfortable, painful and lead to further unnecessary exams and tests in many cases. Also that many times healthcare providers are dismissive of patients' feelings over such exams and engage in questionable tactics -- pressure, scare tactics, etc. -- in order to gain compliance.

Anyway, one poster today chimed in claiming that she is a physician. Here is what she wrote:

"Hi, I'm a doctor, and I think many of you have a valid point that if you have never been sexually active that pap smears may be unnecessary. It is true that HPV causes the majority of cases, but smoking, family history, are also risk factors. If, however, you have ever been sexually active screening is a good idea. 14000 woman are diagnosed with cervical cancer each year, and 4000 woman die each year from cervical cancer. In the 1950s, the death. If a precancerous lesion is found, it can be removed easily with freezing or cutting the lesion out (an in office procedure). The survival rate for woman with precancerous lesions is 100%, and low grade cancers is 90%.
I've seen many misconceptions in these blogs and I encourage you all to consider speaking to doctor before you decide to stop annual screening.
Medicine unfortunatly performs many procedures that people may find appealing. For example, colonoscopy, which is recommended starting at age 45 or 50 depending on risk factors. As an emergency room physician I cannot tell you how many people 60y/o men and woman I diagnosed with sever metastatic colon cancer who didn't have a colonscopy at age 50. And I know numerous people who had cancerous polpys found at age 50, which were removed, and now they are still alive and well. The point is that screening tests exist to prevent people from getting an incurable illness, like advanced colon cancer, or cervical cancer. My advice, these tests exist for your benefit, they save lives, and should be done. If you've ever been sexually active, for god sake get screened. It's not that bad, really."

Some repeated grammar mistakes and odd wording make me wonder if this person really is the Dr. she claims to be or just some nut posting on this other board. Also, I am at a loss as to how an ER doc would diagnose so many cases of advanced colon cancer, etc., rather than a family physician, oncologist or general internist Something about that doesn't add up.

Anyway, aside from my questions over the validity of this poster's stated profession, the kicker is her last line, "It's not that bad, really."

Doctor or not, it is that very attitude and dismissive kind of statement that really gets my dander up on this issue. If it wasn't so bad, really, then I doubt we'd be having so many discussions here and on the other site.

Susanne

Joel Sherman said...

Susanne, please post the link to the other board and I will look at it carefully.
Don't know if I can answer your question as to whether she really is a physician though she surely has some medical knowledge. Not all doctors are very literate or she may have written it hurriedly.
Obviously only a patient can say how bad a test is and everyone has different attitudes which have to be respected. I get regular prostate exams, but many men hate them including some doctors I know. There's no right or wrong answer.

Elizabeth said...

There is now absolutely no doubt that US, German and Australian women are overscreened to their detriment.
The States is worse than Australia...the latter country does not screen virgins and it's 2 yearly...(still too frequent)
I doubt the Germans test virgins, but they recommend yearly smears.
You need only do some brief research on the net to find the States do not have the lowest rates of cervical cancer with all of this screening - but they have VERY high numbers of biopsies.
The RMDeMay article says that 95% of US women will have a colposcopy and usually biopsies in her lifetime. (I think it was posted to this forum..but it was published in the American Jnl of Clinical Pathology in 2000 in an article entitled, "Should we abandon pap smear testing"...)
I've also heard the change to recommendations in the States has been ignored by doctors. Instead of moving to 3 yearly testing from age 30 if you've had three normal results, they continue to test annually.
Also, elderly women being tested and millions who've had complete hysterectomies for non-cancerous conditions - they don't even have a cervix! (The States are not alone there...unethical doctors chasing screening targets also test women who've had complete hysterectomies in the UK and Australia.)

The other comment about colonoscopies.
In Australia, colonoscopies are offered from age 50 IF YOU ARE HIGH RISK...have family history.
Otherwise, no colonoscopy is recommended.
Some Australians were recently offered a free FOT and apparently there is a proposal to introduce a 2 yearly testing program for 50 and over people. (a positive result may lead to colonoscopy)
I read the doctor's post to suggest all 45 or 50 year old people should have colonoscopies.
I think this is another example of the excessiveness of US doctors and over-screening which IMO causes lots of harm to healthy people.
I can't believe these doctors still try to scare women into annual smears when the evidence is now overwhelming and crystal clear....
The States and Germany are the only two countries in the world who advocate yearly smears.
The FACTS speak for themselves...

Anonymous said...

Dr. Sherman,

Here is the link to the blog on which the person claiming to be a Dr. posted a response. It is on the very last page.

http://blogcritics.org/culture/article/unnecessary-pap-smears/


Susanne

Joel Sherman said...

Susanne, I basically agree with your take that if she's a doctor she must be foreign born because she has a poor command of English. As you noted, the strangest statement is that she has diagnosed many cases of colon cancer in the ER. Well she may have seen many cases go through the ER, but very few would get diagnosed in the ER. If a patient comes in with rectal bleeding e.g. they would be admitted and the necessary steps such as colonoscopy would be performed as an inpatient.
Of course her comments may be worth considering even if her credentials are suspect. An individual's personal risk is the best determinant of how often screening should be done. With my family history, I get prostate screening every year. But I was over 60 when I had my first screening colonoscopy.

Elizabeth said...

Dr Sherman,
I agree with you...these tests and exams should be based on personal risk.
Women are not given that option nor the information to make that call.
I've looked at numerous articles in the British Medical Journal and elsewhere that show unnecessary treatment rises with more frequent screening or overscreening and when you screen women under 25. (virgins and women who've had hysterectomies for benign conditions should not be included in screening programs)
Elderly women are also screened in the States.
I was shocked to read a high % of women in their 80's are still screened annually in the States.
Screening usually stops at 50, 55, 60, 65 or 70 elsewhere.
I think both low and high risk women would reject annual smears if they had a choice and had risk information.
I think low risk women may all feel differently about screening.
Some very low risk (virginal couples) might skip screening because of the fairly high risks even with 5 yearly screening or have it very infrequently...
As your risk rises, some might consider the risks with three or five yearly testing are worthwhile...others may not wish to expose themselves to biopsies when the risk of the cancer is low.
All valid positions...when it comes to cancer screening, only you can make that call.
Women are almost universally misled as to the threat of this cancer, in my opinion...
If women are also given honest information on risk, they could make an informed decision and not one based on fear and ignorance.
Women should have the right to protect themselves from risk and unnecessary interventions.
If you want birth control in the States, it's very difficult to avoid over-screening.
Even if you don't want BC, the pressure is still huge.

I have watched all of this for many years and always hoped that things would change...
It HAS started in the UK with quite a few articles questioning the value of the screening programs, the risks of over-treatment and whether women have been fully informed...
There is little discussion in the States and Australia.
(I haven't seen much and I've been looking!)
I was looking at one of the US college student chat rooms and found it totally depressing. The young women fearful of their first "gyn" visit...some admonishing them for leaving it for so long, some had been having these exams since their early teens!
Others talked of colposcopies in their history at the tender age of 20 or 22...
Others reminded women that doctors wouldn't give them BC without these exams.
Others clearly felt brave and mature because they weren't "bothered by the exam"...and urging others to go...
Many thought it was a necessary part of being a responsible woman.
Some thought they'd aleady had cervical cancer, which is very unlikely at their ages...this is fairly common, women who've had biopsies for a false positive think they've had cancer.
I wondered whether they'd feel differently with the facts in front of them and if they were aware of the practices overseas.
I couldn't help but feel sad that their young bodies had already been over-screened and over-treated and all so terribly unnecessary.
Fortunately, we don't have the issue of annual gyn or routine pelvic exams...they are simply not done or recommended outside of the States or Germany. (I certainly haven't been able to find any recommendation from other countries anyway)
No doctor has ever mentioned them to me.
Women should have options...and their decisions accepted by the medical profession.
We are not mass anything, we're individual and healthy women.

Anonymous said...

"Even if you don't want BC, the pressure is still huge."

Thank you for saying that, Elizabeth. I am a virgin. I don't use BC, never have. Don't have any use for it yet and at some point when I do need a BC method, I will choose a different, non-hormonal one, as I am concerned about the possible side effects of BC pills. I find that indeed the pressure is huge, though. As I said in an earlier post, I went to the Dr. several months ago for what I thought was a lump. I was very concerned about that and the Dr. and her nurse just decided as long as I was there, they'd try to push a gyn exam on me. The nurse laid out the tools for the gyn exam as I was sitting in the exam room waiting for the Dr. to show up. It startled me and made me more scared. I didn't appreciate it given the fact that I was already terrified and upset and had not made the appt. for that reason or said anything about wanting/needing a gyn exam. If I had wanted one of those exams, I would have asked for one.

I had to think quickly and say I couldn't do the exam as it was that time of month and I was uncomfortable with cramps. That was all true, but I still felt an enormous amount of pressure from the Dr. and nurse to have the exam and they made it very difficult to decline. Even when they accepted my reason for not wanting the exam, they did not let me leave without warning me that I should be much more concerned about cervical cancer than breast cancer. They didn't really say why I should be so scared other than I needed to have this exam. They tried to pressure and frighten me into having an exam I did not want or make the appt. for. That upsets me and makes me angry. To me, that's not what a good Dr. should do. I go to a Dr. for help, not to be pressured or frightened. Or shamed, as the receptionist in that same office did to me.

And I've had the experience many times of going to a family Dr. for an upper respiratory bug or sore throat and the subject of gyn exams ALWAYS comes up. My family Dr. even has a recording on his telephone line about "schedule your well woman exam today." And starting when I was maybe 12 or 13, the subject of gyn exams came up every time I visited the pediatrician for a sore throat or bug. It's upsetting that a person cannot go to the Dr. for any reason without that coming up.

Elizabeth said...

Anon,
Thanks for sharing your experiences.
I'm not at all surprised...
I think many women feel harassed about screening and gyn exams.
I think we need to go to doctors armed with information.
You could mention that no other country in the world screens virgins for cervical cancer and that other countries do NOT even screen sexually active women before they're 25 or 30...and that annual screening is only recommended in one other country.
You could also mention that routine gyn exams are only recommended in one other country.
So, doctors around the world do not support or recommed the US recommendations for women's routine healthcare.
They really can't argue with the facts.
One doctor said to me, "well, we do it differently in the States"...I responded, "I know and that's why almost all women go throught the unnecessary ordeal of an "abnormal" smear and biopsies caused by a false positive"...
I also pointed out that every healthy woman has a right to make her own decisions about screening.
He was literally stunned...doctors rely on women having no information or having accepted the "facts" they release...they hate us being informed, challenging them and deciding for ourselves whether we'll be screened and how often...
He tried to scare me....but realized he was just sounding ridiculous.
As a very low risk woman, I decided quite a few years ago not to have cervical screening and more recently, I've decided against mammograms.
You can imagine how doctors react when you have never been screened...like it's a national emergency. The question is always, "WHEN was your last smear?"...."Never, I've made an informed decision not to have smears"...WHAT??!!
They fail to understand that I understand the real risk of this cancer for me and I know the real risks of testing.
My decision is thoroughly researched and informed.
Sadly, no doctor has ever given me balanced information or any risk information.
It has always bewildered me why so many doctors do not believe women are entitled to make their own health decisions when it comes to screening. They seem offended, outraged, appalled, shocked or insulted that we should do anything other than follow their advice.
We're labelled non-attenders, refusers, defaulters, negligent, irresponsible...when in fact, we're just exercising a very basic right...to protect ourselves from harm.....that means considering our personal risk, the risks of testing and making a decision that sits comfortably with US.
Be prepared when you visit the doctor...is my advice.

Jack said...

US doctors continue to over-screen women against recommendations calling for reduced testing to contain the harm to healthy women.
What hope do US women have when their own doctors ignore recommendations designed to protect them from harm?
Their doctors are their abusers.
http://pt.wkhealth.com/pt/re/ajog/abstract.
00000447
-200502000-00014.htm;jsessionid=KnCNQ12vhLgbTHL1jtqYyRnyp
Z4j0pPx0Bhytr9J1QJHgpYnKvVx!1156756426!181195628!8091!-1

And the damage continues...every day, in every Clinic.
If they try to protect themselves, they're refused birth control or any other medication they might need...any means is acceptable to get them to have testing that WILL harm most of them.
Why bother with recommendations when doctors are apparently running their own agenda that has nothing to do with the health of their patients? In fact, it's known to be harmful...
Doctors who seek to harm, rather than heal.
Where will this all end?
I think we've hit rock bottom.

Joel Sherman said...

Thanks Jack. Here's the link he just gave.

Anonymous said...

Since some posters have brought up the Finnish and Dutch systems, I decided to do some internet searching and wrote to a Dr. at a clinic for expats in Amsterdam. He did not answer my question about whether or not they require virgins to undergo gyn exams/smear tests, but here is what he had to say:

"In the Netherlands, woman are called for pap smears from their 30th, every 3 years, unless there is an abnormal smear, or a family history of abnormal smears.
Smears are no standard procedure in birth controle prescriptions.
Dr E. Cambridge, MD, GP, Physician, Huisarts
Tourist & Expat Doctor Amsterdam
112 Bloemgracht, 1015TN Amsterdam
30 Rapenburg, 1011 TZ Amsterdam
Tel +31204275011
Fax +31842214003
Email: doctor@planet.nl or expatmc@planet.nl"

Interesting that he says exams are not standard procedure for BC prescriptions.

Susanne

Anonymous said...

"They seem offended, outraged, appalled, shocked or insulted that we should do anything other than follow their advice."

I have had that very experience, Elizabeth and it is frustrating. My experience at the OBGYNs's office is not the only time in the past year I have encountered that attitude.

My family and I have been going to the same dermatologist forever. He has been in practice for a good 35 years. The nurse who has worked with him most of those years is a pill and, unfortunately, is the person with whom you will spend the most time while you are there. I like the Dr., but my last experience at his office has me seriously considering seeking another dermatologist. The nurse is so unpleasant that I'm not sure I could bring myself to go back.

I had a mole on my side removed earlier this year. It was slightly irregular, thus requiring a punch biopsy. Though I've never been a sun-worshipper and don't have a family history of skin cancer, I was still concerned. It turned out to be nothing more than a funny-looking mole, thank goodness.

As I may have mentioned, I lost my mom nearly two years ago to brain cancer and witnessed her go through pure hell in the 17 months before she died. As a result, I've become terrified of anything cancer-related. As with the lump situation, I thought I had something wrong with me when I made the dermatologist appt.

Anyway, I went in and the nurse in a rather urgent tone of voice said, "Oh yeah, that really needs to come off" about the mole in question. Her urgency made me even more scared. I asked a lot of questions - why does it need to come off, what about it makes you think there might be a problem, how is the punch biopsy done, how long does it take for the test results to come back, etc. I also told her I was especially scared because of what had happened to my mom.

I guess I was not supposed to admit fear or ask questions because she said, "If you're this worked up at a doctor's office, then how are you ever going to have a baby and be able to handle going to the OBGYN for that?"

Well, hmm, let's see -- having a baby is a happy occasion and I don't think visiting the Dr. for that would be bad

The nurse then told me I needed to seek psychiatric care and get a prescription for Xanax and/or an antidepressant so I could "handle" visiting a Dr.'s office. She said I had "always been like that" my whole life and "really ought to do something about it."

Funny thing is, I've only been to that Dr's office maybe three times in my 32 years and I hardly see how three short visits qualified the nurse to diagnose me as a basket case. All I did was ask questions and admit I was scared.

Susanne

Elizabeth said...

That must be a conservative doctor - my Dutch friends tell me it's 5 yearly from age 30...and they received NO pressure...entirely up to them.
When it's not tied to birth control, and it never should be, women can choose if and when to screen.
I've attached an article that includes a chart...you'll see US women have LOTS more smears than other women.
Yes, I agree with Jack, the changed recommendations are being universally ignored by doctors.
http://www.mja.com.au/public/
issues/176_11_030602/dic10690_fm.html

Joel Sherman said...

That's a very nice reference, Elizabeth. Anyone interested in the topic should look at it.

Elizabeth said...

Dr, I think that chart speaks for itself...
It seems that more frequent smears are not the answer.
I think many women find this test repulsive...if women are given choices and the facts...they'd be free to protect themselves and consider the real risk of the cancer for them.
I think many high risk women avoid screening because they're sick of the frequent testing and unnecessary follow-up...they are the few that might actually benefit from screening.
I read a few years back that Finland has the lowest rates of cervical cancer in the world...ironically, their women have only 5-7 smears in their lifetime.
You can have 50 and run a very high chance of unnecessary follow-up with the added negative of annual testing OR you could choose just 5 to 7 tests from age 30, catch more cancer and send FAR fewer women for biopsies.
Yet women are given no information and are often forced or misled into testing. Very low risk are rolled in with very high risk.
I think women should be told straight...with this annual testing program, 95%* of women will have a colposcopy and biopsies, but only a very small number will actually have a problem...here is a brochure on colposcopy and these are the risks of this procedure.
These are FACTS...not wild statements.*
Women then go into testing UNDERSTANDING the risk of biopsies for a false positive.
I think if women were handed this chart and given some extra facts, they would be in a better position to protect themselves from both cancer and biopsies. (assuming they didn't live in the States and need BC)
The fact women are not given this information is unacceptable.
It seems screening bodies settle on a program with no regard for the harm to healthy women...it seems to be more about catching cancer.
The reality seems to be that less screening catches more cancer.
More frequent screening just harms more women.
What exactly is the point of all this screening if it doesn't catch more cancer and harms lots more women?

Allie said...

It's annual smears in this country (regardless of the modified recommendations)...that is excessive even for VERY HIGH RISK women.
Imagine the harm being done to no and low risk women having annual smears from their teens.
Even if our doctors are super concerned about liability...how can you justify putting women through that test SO OFTEN?
This is a moral crime, if not actually a crime.
It should be a crime, knowingly harming women.
No wonder I've always disliked doctors and never trusted them.
Having a baby is no fun in this country either...a very medical experience.
My cousin had internal exams all the way through her normal pregnancy. My sister who now lives in the UK, had one at the start, one during the labor and one a few weeks after delivery.
We worked out US women have almost 5 times the number of exams in a normal pregnancy.
That arrogant nurse by the way...I think they throw that at any woman who has anything negative to say about an exam or test or wants answers.
We're not supposed to be "bothered" because we give birth...get used to it is the attitude.
I think we are all more accepting of exams and tests when we can see the need...and we can find the right doctor for us.
All invasive exams should be kept to the bare minimum though...
When we're expected to submit frequently to a nasty and embarrassing test when we're fit and healthy...then I want facts and a say in whether I have the test or not and how often...

Anonymous said...

Dr. Sherman,

I may be comparing apples to oranges here, but according to the National Cancer Institute (http://www.cancer.gov/cancertopics/factsheet/risk/brain-tumor-study), about 19,000 people are diagnosed with primary brain cancer each year. My mother was one of them. Her Drs. told us brain cancer was exceedingly rare and the causes are pretty much unknown. They said it was just a case of extremely bad luck that an otherwise healthy person like my mom happened to get it.

So you have about 19,000 people per year diagnosed with this disease, which is considered rare, but I don't recall there being a push for patients to undergo annual brain scans/MRIs to make sure everything is OK up there. I realize that is probably not done because it wouldn't be considered practical and cost may be an issue, but I can't help wondering about that when the issue of smear tests comes up. I think the rate of cervical cancer diagnoses is somewhere around 11,000 a year -- far fewer than primary brain cancer -- yet women everywhere are being pressured into having these yearly exams and tests for something that doesn't happen all that often. The tests aren't foolproof and may cause more harm than good to healthy, low-risk women. I would think it would serve all patients better if Drs. considered individual risk, individual health history and gave all the facts about these tests, the risks and possible outcomes (such as false positives) and left it at that. Instead, everyone is rolled into one blanket group and we are pressured, shamed or frightened into doing something so very unpleasant that may not benefit us. There doesn't seem to be much logic to that.

Susanne

Hexanchus said...

Just a thought....

The nurse's statement "The nurse then told me I needed to seek psychiatric care and get a prescription for Xanax and/or an antidepressant so I could "handle" visiting a Dr.'s office." sounds like she is making a medical diagnosis and recommending treatment (psychiatrist referral & antidepressant). I somehow think this is outside her scope of practice. Perhaps a complaint to the BON would be in order in situations like this.....

MER said...

"The nurse then told me I needed to seek psychiatric care and get a prescription for Xanax and/or an antidepressant so I could "handle" visiting a Dr.'s office."

These are the kinds of assumptions that need to be nipped in the bud. It's the quick fix -- drugs. And it assumes that people who are modesty concerns have some underlying psychiatric condition that needs treatment. A formal complaint may be in order, but as effective is an immediate chastisement and a talk with the nurse's supervisor, followed by a letter.
Human psychology is complicated. Keep in mind that the nurse may think she has the best interest of the patient in mind -- getting her to see the doctor any cost. Possible good motives but poor methods.

Anonymous said...

Hexanchus,

Indeed, I think it was outside her scope of practice. Complaining to the BON wouldn't get me anywhere -- my word against hers. I just need to remind myself that I'm not the only patient she's treated that way. My family members have also found her to be unpleasant in a know-it-all, in-your-face sort of way.

She is not the only medical professional I've encountered with that attitude, though. It has happened at other Dr.'s offices too in regard to the gyn exam. It's a do-as-your-told, don't-question-me kind of thing, which is very frustrating and upsetting. If I refuse or question something, I am subjected to shaming, pressuring or scare tactics. That's not something anyone should be receiving from a healthcare professional. Ever.

Susanne

Hexanchus said...

MER,

You wrote, "These are the kinds of assumptions that need to be nipped in the bud. It's the quick fix -- drugs. ".

I couldn't agree more.

While I might like to give the nurse in Susanne's experience the benefit of the doubt regarding her intentions, the pattern of her behavior based on her reported comments says otherwise.

For example, the trigger event for Susanne's expressed concern was "the nurse in a rather urgent tone of voice said, "Oh yeah, that really needs to come off" about the mole in question". As you, I and others have said repeatedly, context is important. Why did the nurse feel compelled to even make that statement, let alone in the apparent tone she used. Again, it's very close to making a diagnostic assessment - that's the doctor's job, not her's. Why wind somebody up unnecessarily? Unless of course it was to inflate or exaggerate her own level of importance in the process...

The nurse's concern should be to calmly assist the patient, not wind them up, and when they react in fear or concern, accuse them of being emotionally unstable and in need of psychiatric treatment and medication.

Susanne,

You wrote in your post "I like the Dr., but my last experience at his office has me seriously considering seeking another dermatologist. The nurse is so unpleasant that I'm not sure I could bring myself to go back." You need to tell the doctor this, then follow it up in writing. If you really like this doctor, then give him a chance to fix the problem, or at least try to mitigate it to your satisfaction.

Disgusted Boyfriend said...

Susanne, Never assume your complaint is not "worth it"...
You don't know whats been going on...your complaint may be the third they've had that week.
My GF made a complaint at my biding about a doctor verbally abusing her after she declined a gyn exam. She'd only agreed to see this unknown doctor to her, because she just needed more medication for recurring migraine headaches.
Needless to say, this was not a one-off...
Never assume your complaint is not "worth it" or "your word against his/her"...your complaint may be all they need to take the matter further.
One complaint may be a misunderstanding, two complaints and the red flag goes up....three complaints...time to move....it's called pattern of conduct...the evidence of previous history.
Multiple complainants make a strong case.

Anonymous said...

I agree...this test is seriously over done and ends up hurting us.
Doctors hate women travelling to other countries and finding out the yearly pelvic thing is not done, considered harmful!
Then we find out that smears every year are BAD for us and more likely to harm our health.
We're told we're doing the right thing, we're misled and end up with this test and the aftermath constantly in our lives - too early and too often...and even when we'd be excluded altogether overseas. (virgins)
A woman asked the Dr on another blog whether smears were bad for young women...she now knew that other countries don't test young women and when they start testing, it's infrequent...
The next poster said a foreign doctor told her she didn't need smears because she and her husband were virgins.
The Dr freaked out and said to these very valid questions that she followed US recommendations and they'd get no support saying smears and pelvic exams were unnecessary on her forum. She added, "Get your pelvics and paps, ladies!"....and closed the thread, halting any further mutinous rumblings.
I guess it's like asking a butcher whether you should become a vegetarian...vested interest.
It is disgusting that US doctors refuse to even discuss the more moderate programs around the world that achieve more than ours and put fewer women through biopsies. (fewer by miles)
Many of my friends have been having yearly smears since they were 16 even though they're not sexually active at all.
I think these doctors should be prosecuted...these young girls are not at risk and you're adding an invasive test to their lives that is very likely to lead to biopsies of their young bodies.
Our doctors actions and advice endangers our health and lives.
These girls think they're protected from cancer, having accepted their doctors lectures...they're not even at risk of this cancer and their doctors know it.
Why do our doctors do this?
IT IS PURE MADNESS AND I DO NOT UNDERSTAND.
Bettina

Joel Sherman said...

Bettina, if that thread is still on the other blog, please give a link to it.

Anonymous said...

http://theblogthatatemanhattan.blogspot.com/2007
/06/performing-pelvic-exam.html

I think these women deserved answers.
Why are pelvic exams almost mandatory here every year and not done elsewhere?
Why isn't it acceptable for us to even question the need and value of this exam?
Why do we screen virgins and young women with clear evidence of harm?
Why do we screen all women regardless of risk when we know the risk of biopsies goes up?
Why can't we question the intervals to avoid biopsies?
Why are they mandatory in this country to get birth control and not elsewhere?
Why are women stopped from voicing their concerns to doctors?
Bettina

Richard P said...

I can't believe I'm reading this...
I had thought that every woman just accepted this sub-human treatment.
The manipulation of women in our health system is #%@%*...words fail me.
I'm at the end of my patience.
My wife decided to follow more modest guidelines for womens health care after spending a few years in Europe as a teenager.
Fine...so far
Upon her return, we get together.
A year later, she decides she'd like to use birth control pills.
She has decided never to have pelvic exams unless she has symptoms.
This is the advice of doctors in developed countries around the world.
She does not want breast exams either until she's older.
Again, she's following a more relaxed schedule that reduces the risks of further exploration.
She has decided no smear tests until she's 30.
She has sound reasoning for all of these things. She's not an impulsive or irrational person...in fact, she's an accomplished professional woman.

The trip to the doctor makes clear SHE is not entitled to make these decisions.

She's told pelvic and breast exam and yearly smear tests OR she doesn't get the pills.
My wife (by this stage) believes when she turns 30, she'll get the Pills.
At that age, she planned to start smears.
We "manage" for the intervening years.
At almost 30, she returns to the doctor.
The doctor will not do the smear in isolation.
My wife must agree to the whole gynecological session OR no pills.
At this point, we're shocked and furious we could be facing these problems in THIS country.
We're currently staying with friends in Australia.
My wife FINALLY got pills with no exams at all. She had her blood pressure taken and that was it.
No smear was taken as she had her period.
No pressure was applied though...it was her decision whether she had smears in the future. The doctor readily agreed over-treatment was a major drawback with smears and that she was very low risk given our sexual histories.
I didn't know my wife was even seeing a doctor.
We're not sure whether we'll even use the Pills.
My feeling is why start something we can't keep using. It just puts more pressure on us to give in to our doctors.

My wife now has the following options.
a) Agree to abide by our doctor's rules and get birth control.
No modification allowed....
b) No pills and she still can't follow her preferred health plan.
A smear every five years until she's 50 or so.
Three doctors have refused to give her a smear unless she agrees to everything.
One agreed to give her the smear, but would not give her pills...so she refused.
The doctors have all expressed deep and urgent concern that she hasn't had a smear at this advanced age. (almost 31)
It doesn't bother my wife because she knows what happens elsewhere and knows this is all designed to scare her.

The end result my wife won't have smears and we won't be able to use birth control pills on a continuing basis.
It will be whenever we can get them.
She's over all of it and is not prepared to keep arguing with doctors.
She's decided no smears is safer, with less risk than all the risks of complying with their demands.
I think doctors feel women will agree eventually or that their partners will pressure them.
That will never happen...it is now a matter of principle.

I'm prepared to take responsibility for birth control for as long as it takes, because I see the unfairness of the treatment our women receive from our doctors.
The attitude is totally inflexible and arrogant.
Women really have no rights in these matters.
It was nice to vent...thank you for that...

Katie said...

Some of you may care to look at a thesis written on cervical screening in 2004.
It's quite long, however you can refer to the index and read selected sections that interest you.
I found the sections on the psychological tactics used against women fascinating and I identified with lots of it
particularly, the tone and wording of the "invitation" for screening. It is assumed that you'll attend, you are not asked or invited to attend.
Clearly, lots of thought has gone into manipulating women into screening and deterring them from looking into the negatives of testing.

It also discusses the impact of screening on healthy people.
Screening turns us all into the "not sick yet" category.
We must be checked to be reassured all is well. It is no longer proper to assume we're well.
Many women would not have given cervical cancer a second thought before the screening program.
Most of us had never heard of anyone getting cervical cancer.
Now many women have an inflated sense of the risk of this cancer and of the importance of the test.
We almost have no choice as we're made to feel "morally" obliged to attend screening.
The wording used by the screeners suggests it's the only responsible and mature position.
Brainwashing, imprinting, conditioning all comes to mind.

Instead of the sick and well, it is now the sick and not sick yet.
It also discusses the regulation and control of women's bodies.
I resent the manipulation that is worked into the program.
I've always considered it improper and disrespectful.
I have major reservations about screening because of the way it is demanded of women and certainly, not offered to us.

If screening is offered together with all the facts and no psychological tactics, women could choose whether to have screening or not.
Instead, that was rejected in favour of the current promotion of the program.
I think the psychological manipulation of women often to a negative conclusion is abhorrent.

http://etheses.nottingham.ac.uk/485/1/
Full_Thesis.pdf

Hexanchus said...

Richard P.,

Check out Planned Parenthood - they have a program where they will prescribe hormonal BC without the pelvic exam/PAP smear. Although they will encourage the exam, they will still issue the prescription if the patient declines.

Katie,

Nice reference!

Hexanchus said...

The theme that I see running through this thread is that providers are pressuring American women to undergo these screening exams without giving them complete information with regard to the efficacy, accuracy and reliability of these tests/exams.

My suggestion ladies, is to hold their feet to the fire. Be proactive, ask them hard questions and make them give you substantive answers - don't accept vague references or assurances. If they tell you a pelvic/PAP is necessary for a BC prescription, ask for evidence based studies to back that up....and be prepared with your own that show otherwise.

Make up a written list and take it with you to the appointment.

Some simple examples:
Why are you recommending this test/exam?
What does this test/exam detect?
What are the risks?
How accurate is it?
If it's positive, what happens next?
What is the rate of false positive results?
What are all the potential adverse effects of a false positive?
What is the actual statistical comparative risk of having versus not having this test/exam? How is this affected by individual risk factors?

You get the idea......make them justify what they are recommending.

Four that I always ask in addition to any others:
What is the sensitivity?
What is the specificity?
What is the positive predictive value?
What is the negative predictive value?

These are statistical values that quantify the accuracy and reliability of the test. (Wikipedia has an excellent explanation of them, so I won't do so here.) In my opinion, any provider that can't accurately answer them with respect to a test/exam/procedure they are recommending has no business recommending that test/exam/procedure.

Joel Sherman said...

I have sent out this email to the physician referred to in Bettina's post concerning the physician's blog where she dismisses the ladies concerns about the need for pap smears:

Dr Polaneczky,
I am a physician who also runs a blog. Mine concerns patient privacy mainly from a patient's point of view.
I started a thread some months ago and have recently been inundated by women complaining that they are forced to get pelvic exams for contraception and for pap smears. One mentioned your curt dismissal of their position.
I have read through all the information they've posted and I believe they indeed have a valid point. Most of the posters started out with European guidelines and were shocked to be treated differently here. They claim that European countries do only a small percentage of the pap smears we do and they have a lower rate of cervical cancer and a much lower rate of negative biopsies. Also pelvic exams are not mandatory there before being started on BC pills. In contrast, a significant percentage of American doctors insist on yearly pelvics and paps, sometimes in young even virginal women. This is against many guidelines. For instance, the National Cancer Institute says that pap smears every 3 years is acceptable in low risk women:
http://www.cancer.gov/cancertopics/factsheet/detection/Pap-test
The guidelines you quoted were very vague.
I also note that Planned Parenthood is willing to give out BC pills without pelvic exams, though they do recommend them.
But I believe the women make a valid case. Screening tests should be based on risk vs safety concerns. It is well recognized now that prostate screening should be voluntary due to the risks involved with large number of men getting unnecessary treatment. I don't see why the decision to have cervical cancer screening should be treated any differently.
I by the way get regular prostate screening and my wife gets yearly exams. But I see no reason to impose our practice on others when there is clearly controversy and another point of view.


I have no idea whether I will get a response.

Margaret Polaneczky, MD (aka TBTAM) said...

Dr Sherman –

I closed the comments on my post because I was getting too many comments containing misinformation and statements unsupported by data that I had neither the time nor the inclination to counter. These comments went unpublished. When I realize it is going to take me longer to respond to every accusation or statement in a comment than to write a new post, I just have to give up the discussion.

One of the challenges in running a medical blog is being certain that nothing that is there under my masthead would ever mislead or misinform. That means I have an obligation to filter every comment and challenge any comments made that I think may be incorrect or with which I disagree, so that there is never any question that I am giving advice that runs counter to my clinical practice. Once a discussion seems to have made the points that need to be made, and I begin to get mostly comments with misinformation or unsubstantiated generalizations, I need to close comments and get back to my day job.

The comments I allowed to be published on the blog were fine by me – I answered most of them I believe (though I realize now that the last question went unanswered, so I will post a quick comment addressing that one.) I will add a new comment to make it clearer why I closed comments – reading the post now, it does read as though I were dissing the discussion that is there – and I am not. I was responding to the multiple unpublished comments. Apologies to those who wanted to continue an intelligent discussion – I just don’t have the time right now to filter through the misinformation that was being sent to me on a daily basis.

You seem to have created a great forum for this discussion and have the time to step into the fray, so enjoy! I’ll link to you at the end of the comments section on my blog so folks can head over there to talk.

Thanks for your feedback, it is appreciated.

Peggy

Anonymous said...

Thank you for contacting the OBGYN blogger, Dr. Sherman. I am curious to see her response -- if she even sends one -- to your thoughts and to those of us who are concerned about this issue.

I took a cue from you and from other posters on here who mentioned the Finnish attitudes toward screening. I sent an email to a Finnish OBGYN, Dr. Aila Tiitinen, who also is a professor of medicine at Helsinki University, and asked her questions regarding screening in Finland and what is or is not required of women there. I will post her reply when I hear back from her.

Susanne

Anonymous said...

I've actually consulted a Finnish doctor and found her very flexible and reasonable.
You might get a slightly harder line from a Professor of Gynecology.
Certainly, the doctor I saw was very open about the low risk of this cancer (even for someone high risk) and the dangers of testing...mainly going through upsetting procedures because of the high number of false positives.
She also took me through the problems that can follow biopsies.
I was told by my finnish friends that this doctor was not unusual.

I've also been told by doctors that I was misinformed...even when I produced a medical journal, they dismissed the contents. There was always a reason why they should be believed and anything that presented another point of view should be dismissed.
Doctors are very defensive when women challenge them about screening. We don't have routine gyn exams.
I always believe people on safe and solid ground are happy to meet any argument and not cut it off at the knees.
That usually means...stay away, don't look too closely or you'll get to the truth!

Anonymous said...

I fear this obsession with cervical and gyn cancers will mean lots more women dying from heart disease.
Our lifestyle and weight issues are overshadowed by all this testing and examining for a fairly rare cancer.
I read that heart disease in women is largely overlooked and ignored by doctors.
It kills more women than anything else.
The thesis talks about that...making something much more of a threat than it really is, to achieve your end (screening)
In other words, mislead...
We now have a skewed idea of the real threats to our lives.
We hear endless talk about smears and gyn exams, nothing about heart disease, the number one killer of women.
Many women avoid doctors because of the pressure to have invasive exams and testing and we end up receiving no or very little health care.
I haven't seen a doctor in 10 years.
My grandmothers and great-aunts all died from heart disease/attacks, NOT cervical or any other kind of cancer.
I wouldn't mind talking to a doctor about my heart, having it checked and my weight, cholesterol and pulse.
I don't...because it always comes back to gyn exams and pap smears.
Because the only way to avoid these gyn exams and the pressure, is to avoid the doctor...everything else is neglected.
Even the simple checks that wouldn't bother most of us that would protect us from the top killer of women are just too difficult.

Poppy

Anonymous said...

I was listening to Dr Radio on Serius Radio, it was mens health with several urologist discussing prostate canscer screening. I could not help but draw the similarities with pelvic exams. The discussion was that while on the surface regular screening seemed to be a good idea, when they looked at the data differently...they questioned the fact that they had to screen so many to find the ones that actually had problems, they questioned whether it out wieghed the number of false positves and the results of unneeded treatments. The standard of annual screening they contended had the possiblity of wasting money or screening and unneeded treatments....I think it is a societal thing to screen extensively.....the real wrong is demanding rather than suggesting and tieing that to birth control if the two have nothing in common.......now the question becomes how do you seperate the two...does it take legislation....

Anonymous said...

"We hear endless talk about smears and gyn exams, nothing about heart disease, the number one killer of women."

Poppy, that's the same point made in this piece by a Canadian journalist named Rondi Adamson. She examines the overwhelming focus on breast cancer and how other women's illnesses such as heart disease don't seem to get the coverage they deserve. It's definitely an interesting read:

http://www.ifeminists.com/introduction/editorials/2002/1029c.html

anne said...

Thank you Dr Sherman.
It takes an open minded and brave doctor to say anything remotely negative about cervical screening.
Every time a doctor is challenged about their attitude or conduct that falls short, we move a step forward...
Maybe it will make them stop and think in the future.

Alan, I see parallels between prostate, breast and cervical screening.
All three produce worrying numbers of false positives that can lead to serious harm.
I've read prostate screening can lead to VERY serious harm because the gland is well inside your body and hard to biopsy.
The difference...
I've read numerous reports on the dangers of prostate screening advising men to be careful..."it produces too many false positives", "it's unreliable"...
So is breast and cervical screening.
We're hearing more about mammograms and the real risks of testing...but that has only been in the last 3 or so years. (UK)
Cervical cancer screening has somehow managed to avoid close scrutiny.
Doctors and others seem afraid to say anything critical about cervical screening. The reaction is usually savage.
It's never been possible for women to really decide whether they want screening or not.
We received little information and a deliberate campaign was run to "round up" women and use all sorts of tactics to pressure and force us to have screening.
It became something that was expected of us.
We were never to question the need, value or risks of the test or to apply our health history to the cancer.
There is as a result lots of misinformation, hysteria, fear and resentment surrounding the test.
It was something "done" to us in many cases, not something we volunteered for after reviewing all the evidence.
I don't understand why this was an acceptable approach with women's health...men are being treated very differently.
I even saw an article that said, "Men, don't have prostate testing!"...(attached)
I would love to see that for women's screening tests.

Cervical screening - uncommon cancer, very unpleasant test(some find it painful), inaccurate test and high over-treatment. (often leading to harm)
Breast - common, inaccurate test and possibly harmful in itself, high numbers of biopsies, surgery, treatment for false positives or for things unlikely to ever bother the woman.
Prostate - common, inaccurate test leading to biopsies and potentially very serious harm.

Yet of the three tests, the cervical screening seems to be the one that should have been MOST likely to be challenged...uncommon cancer, unpleasant test, inaccurate and possibly leading to harm.
Yet it is challenged the least...by miles.

Many women feel our lives have been negatively affected by the introduction of cervical screening. (in particular)
We can avoid mammograms...they have yet to find a way of "rounding" us up and a few vocal critics are making things difficult for them.
Critics that can't be dismissed as ratbags.
I have never had cervical screening.
Why is it that I would never admit that to anyone?
Why do I feel like I've broken the law and should be arrested?
It should be my right to choose not to screen.
Yet that is not the case.
http://open.salon.com/blog/amytuteurmd/2009/03
/18/dont_get_screened_for_prostate_cancer

Joel Sherman said...

Thanks for link on prostate cancer Anne. But I want to make clear that I don't agree with it.
The danger is not in getting screened for prostate cancer, but in the treatment chosen to follow the diagnosis.
No one is mandated to follow the diagnosis with immediate surgery or radiation. It is perfectly feasible to take a wait and see approach getting frequent PSAs to see how rapidly the tumor is growing.
That's what many men should do. I personally would not wait because I have a family history of aggressive prostate cancer. These are individual decisions. I believe most men should get screened, but if cancer is found consider all options very carefully.

Anne said...

I really don't know enough about prostate screening to say either way...although my husband has just decided, in conjunction with his doctor, not to have testing.
There is no family history though...
The point I was making was more that there is discussion about prostate screening, arguments to and fro, the risks and the benefits...and you can make an informed decision together with your doctor.
I don't think that has ever happened with cervical cancer...it's almost a conspiracy of silence.
I would only have considered screening if I'd been high risk.
It was impossible to get that information from a doctor.
"ALL women are at risk"....
I knew there MUST be degrees of risk.
I also know it was never a major killer of women in the developed world.
I had to find the information myself and make the decision without my doctor's help.
Our doctors seems to think we don't have the right to refuse cervical screening.
This is a cancer SCREENING test that requires informed consent.
How did we depart so far from that?
I've never felt the same pressure to have mammograms...not even close.
In the last few years a fair bit of evidence against mammograms has been in the papers.
I doubt they'll ever achieve the high targets for breast cancer screening.
Women know too much and many are walking away from the test.
I think doctors struggle to pressure us because they don't do the test in their rooms.
I've found many doctors are indifferent about mammograms...it's the responsibility of BreastScreen.
Also, doctors don't receive incentives to reach high targets with mammograms.
I think it's telling that breast cancer kills far more women than cervical cancer, yet the bulk of the pressure and tactics involves cervical screening. A test that will not benefit the vast majority of women and ends up sending many healthy women for biopsies.
I read in one medical journal a GP's comment about cervical screening, "We're not concerned about missing a cancer, just missing our target"...
How can you respect a woman's right to choose when the government pays doctors large sums of money to screen 80% of their female patients?
Is it ethical to pressure women so you reach your target or even screen ineligible women? (and that happens)
I think it should be noted we're talking about a very invasive exam here....

I take the view if you have cervical or breast screening, it usually means moving down the diagnostic line when you get an abnormal result.
I know they've tried to send fewer women for biopsies in the last couple of years...asking them to wait in some cases and have a repeat test in a year.
This isn't working according to my GP.
Women now see cervical cancer as a HUGE threat to their lives. (because of the pressure, exaggerations and scare mongering that has been going on for many years)
Most women won't wait and demand an immediate referral.
I know myself when my sister had a problem with her first mammogram, the Dr said she could wait 6 months or have biopsies.
She was terrified and refused to wait 6 months.
She had the biopsies a few days after the call back letter.

I don't know whether prostate cancer screening is different...but I know women rarely want to wait any length of time, stew and worry, before finding out whether they have a problem.
Six months or a year is an eternity when you're talking about cancer. The threat of these cancers has been deliberately blown out of all proportion and now that is working against doctors trying to reduce the number of biopsies.

I envied my husband that he could make an informed decision about prostate screening WITH his doctor's help and advice.
I've never felt that doctors were on our side.

Anonymous said...

I agree with lots of the statements here...
It is not really a cancer screening test offered to healthy people...in the sense you consider the evidence and make an informed choice.
It is assumed all women will or should have the test.
Refusal is unacceptable.
When screening figures fall, the headlines read, "thousands of women fail to screen and their lives are at risk..." then they outline the measures they'll adopt to get to these women.
It doesn't seem to occur to anyone that it's not against the law to throw your invitation to screen in the bin.
We don't HAVE to have screening tests.
Cancer screening is supposed to be voluntary...but it has never been that...it is assumed and demanded of us.
A great article is "Reaching targets in the national cervical screening programme: Are current practices unethical?" by P Foster and CM Anderson, J. Med. Ethics 1998;24;151-157
It's worth a read.

Joel Sherman said...

I certainly agree that informed consent is missing in cervical cancer screening. There should be no pressure on women to submit to it. This is being recognized now but the word doesn't seem to have fully gotten out. I think the situation is better for prostate screening because PSA is a new test and was therefore looked at with modern ideas and outcome data. But the pap smear has been around for decades and it was dogma for years that we all learned that annual screening was necessary. It will take awhile for that to be unlearned by physicians, but activist patients will certainly speed that process.

Joel Sherman said...

This link posted by anonymous on the 16th is worth reading. Written in 2002, it talks about the political emphasis put on breast cancer diverting attention from other women's diseases. Some such as heart disease kill more women. The article doesn't mention the only possible justification for that which is that breast cancer tends to kill more young women whereas heart disease is more a disease of elderly women.
Men's health advocates will also find the statistics she quotes comparing the money spent on breast cancer vs. men's diseases of interest.

PH said...

I think "womens magazines" are misinforming and frightening women.
They always talk about self-examination of the breasts...yet our doctors have been saying for years that its a bad idea and leads to follow-up treatment for benign things.
Mens magaizines do the same with testicular self-exam. (not recommended by our doctors)
The teen magazines stress the importance of pap smears in almost a fashionable way without mentioning the risks.
It's presented as an essential test for all girls "for your general health".
That is simply not true and a gross over-simplification.
My niece asked my sister about pap smears when she was 11 after looking at a friend's tween magazine.
We're now scaring our children about cervical cancer.
I also strongly disagree with putting the entire spotlight on this test.
It should be more about what causes this cancer and protecting ourselves at that level.
The test is not perfect, far from it...
I would not want to be having unprotected sex with a few men every month from the age of 16 and smoking and confidently expecting a smear to cover the risk.
The message many women get is have a smear and all will be well.
Most magazines don't even mention the symptoms of cervical cancer.
One third of all women who get this cancer had one or more NORMAL pap smears.
AND Pap smears are unreliable detecting the very aggressive case of cancer in an under 30 woman.
That is why they are not recommended for women under 25 or 30 in many countries. They don't detect the rare case and send lots of others for biopsies.
Women don't know about the one third of women with false negatives because it is NEVER mentioned...
I think we should spend less money on scaring women and more money educating women on lifestyle choices.
I know a US study showed college girls who limited partners and used condoms every time had much less HPV.
I didn't read that in the paper. (sadly!)

PH said...

PH again,
Here is one of the articles talking about condom use and increased protection from HPV

http://www.msnbc.msn.com/id/13461194

Anonymous said...

Thank you Dr Sherman for reminding doctors that we have rights too...
I thought the Doctor's response was fairly typical.
She says there may be a case for an actual virgin to forgo screening. (no sexual activity at all)
In fact, that is a very unfair statement.
It implies you're moving into uncertain or shady territory when in fact, that is the norm in every other country.
Virgins don't have smears or gyn exams.
No one has gyn exams in fact...
To then go on and say the risks of biopsies is minimal because of new HPV testing misses the point entirely...
It seems there is a readiness to put us through routine and very embarrassing exams when there is no need for them...in fact they may not be in our best interests.
Why would anyone choose to have smears when there is no need or they are very low risk?
Do doctors think this test is fun for us or we should be happy to have these exams?
I find that reasoning totally lacking in understanding....really insensitive.
Most women find these sorts of exams very difficult.
I think they should only be done when it's absolutely essential or when the woman wants it done.
It also seemed like that doctor didn't address the case of a virginal couple.
I know doctors never mention us.
I've never been able to get an answer.
I think we're to assume our husbands will be unfaithful so we should be treated like everyone else.
Surely, that should be my decision...they don't even know my husband.
How unfair to assume all men are unfaithful anyway...
There are levels of risk and we should have the right to that information and to choose what screening, if any, is appropriate for our level of risk.
My doctor also said that birth control pills would not be possible if I wouldn't have smears.
Like the earlier poster, we "manage" as well.

Lavinia said...

I'm constantly amazed at the things floating around about cervical cancer and pap smears.
I'm not surprised because women have had to scratch around to get answers.
There has been no release of honest information.
They wouldn't want to put us off with the facts and risks.

I saw this study recently that shows the lack of understanding we have of the risks of this testing and exactly what it's all about.
Women seriously underestimated the number of abnormal smears and women having colposcopy.
They were therefore unaware of the real risk of testing.
1 in 12 smears are abnormal (even higher in young women)...most women got that wrong.
1 in 50 have colposcopies (that figure would be higher in countries that test more often)
I think when we all see woman after woman having biopsies, we become very scared thinking this cancer is all around us.
It doesn't occur to most of us that the test is just wrong in so many cases.
I think that makes us even more afraid of this cancer, when we should be concerned about the risks of having a test that is so often just plain wrong.
Most women had a poor knowledge of HPV.
I found it sad really...so many women have great faith in this test because of the constant and positive "information" we receive everywhere we turn only to find we don't know the whole story.
Many of us feel misled and may have suffered because of our trust and faith in our doctor's advice and the test.
I hope some of the facts find their way to more women.

http://her.oxfordjournals.org/cgi/content/full/17
/6/706#DUNCAN-1992

Anonymous said...

I see Dr Polaneczky didn't respond to the real issue you raise...cervical screening should be voluntary.
It would come as a almost absurd suggestion to most doctors.
Perhaps she's busy looking up informed consent in a medical dictionary.
Hope so....

Anonymous said...

I don't understand...
I've read many of these articles and papers and feel quite shocked and upset.
How has it been possible to keep all of this from women?
I can't believe that doctors did not feel morally and ethically obliged to speak up.
How could this test have become routine when there are serious drawbacks?
Who gave these people permission to take risks with my health?
I think this is possibly the most scandalous abuse of women's rights in living memory.
I intend to send a letter to a news program in Austalia that specializes in investigative journalism.
Something needs to be done to get this information to all women.

frank said...

This is a disturbing piece in the NY Times...
Even elderly women in homes are having smears and mammograms ever year whether they want them or not and regardless of whether they'd even accept treatment if cancer were found.
I wonder whether President Obama will shake up things and stop the excessive and unnecessary testing of people regardless of consent and/or need.
Maybe common sense and respect for patient choice is not far away.
http://newoldage.blogs.nytimes.com/2009/02/18/
government-intrusion-in-health-care-bring-it-on/

Anonymous said...

The Oct. issue of Self contains a multi-page section featuring scary accounts of women diagnosed with not only breast but other cancers. This "handbook" includes such tips as "Half of sexually active women and men contract HPV. Don't dodge the gyno!"

Of course there is a cervical cancer story, but the young woman in it had cervical dysplasia, not cancer.

The story barely brushes the subject of women's modesty and mentions nothing about risks of screening, except saying after the young woman underwent a cone biopsy, she experienced excessive bleeding and was on bed rest for four weeks. She is now a spokeswoman for a cervical cancer coalition and "speaks frankly about her brush with cervical cancer."

I find it frustrating that women's magazines are trotting out the same old pat advice but not ever mentioning possible risks or discussing overtreatment and overscreening.

The overriding message seems to be, "Be afraid. Be very afraid." and everything seems to be one-sided in favor of frequent tests, exams, scans and such. It's a prime example of what some folks have termed the "medicalization" of women's lives. It's as though we are being conditioned to be afraid of our bodies all the time. Never are we to assume for a moment that we might be healthy.

I can't help but wonder if this sort of fearmongering is detrimental in and of itself to women's health.

Elizabeth said...

Totally agree...
Every woman who has dysplasia thinks she either had cancer or was saved just in time.
I was reading that cervical dysplasia is so common it may be a normal thing the body does all the time in the process of repair. One expert calls it the "dysplasia swamp"...
http://www.guardian.co.uk/society/2003/nov/
15/medicineandhealth.publichealth

Most of this dysplasia does not progress to cancer.
I think when the understanding of the progression of disease is so poor and unpredictable you have to question the benefit of screening programs.
The "We don't know the very small number who'll get cancer, so we'll treat everyone with dysplasia" is too destructive an approach for me.
I know they tried selective screening for high risk groups in Scandanavia and it didn't work...possibly because of the link between promiscuity and cervical cancer.
People heard it as a calling forward of the "easy" women.
A few years ago a senior female politician (I think) said screening everyone including low risk women was an attempt to "destigmatize" the disease.
I agree most women have been misled as to the threat of this cancer and have an inflated sense of their own risk.
I don't entirely agree with the promiscuity theory.
I know women can be virgins and if their partner has had a few sexual partners, he can give her one of the virulent strains of HPV and she then has a small risk of cancer. It is true the more sexual partners you or your partner have had, the more likely you have HPV.
That doesn't mean you'll get cancer by any means, but as I understand it, you must have HPV to be at risk.
I do think the lack of hard facts is disgusting, the incorrect statements,
"I had cervical cancer"...when she had "dysplasia" which is common as dirt and not cancer.
None of this is helpful.
In fact these publications are being irresponsible publishing misleading and incorrect information.
They should be forced to publish a retraction or interview an expert to correct any incorrect impression left by the interviewee.
They should be made more accountable for publishing these sorts of blatantly incorrect statements.
In this case women are left thinking dysplasia is cancer and that is not correct. It greatly and unfairly increases the anxiety of women diagnosed with dysplasia...which is most screened women.
Women should also know "abnormal" smears are very common so they don't panic and assume the worst.

With women's cancers, I think we have these reports you describe from time to time in response to any recent probing or critical assessment of screening.
It's time to frighten the women again.
I know when "Spectrum" released a damning report on cervical screening a few years back, the response was really "over the top" and clearly intended to scare women in a very unfair and dishonest way.
They at no point directly met the arguments of that report.
I think that may be the reason so many are reluctant to make any negative comments. The screening zealots don't play fair and can be very nasty.

Joel Sherman said...

I think it is important to link to the official recommendations of the American College of Obstetricians and Gynecologists concerning pap smears.
I'm sure many of you don't agree with them, but you should be aware of them. They recommend a pap smear at age 21 or after 3 years of sexual activity, whichever comes first. After that they recommend they should be repeated every 1-3 years depending on your individual circumstances.
Interestingly, they recommend that a yearly pelvic exam be done, but if a speculum is used, a pap smear may not be necessary.

Elizabeth said...

I wonder how they justify these recommendations.

FACT: No country in the world recommends smears for women who've never been sexually active.

- Routine/yearly pelvic exams are (as far as I'm aware) only recommended in the States and Germany.
At the very least they are of debatable value and women should not be misled into thinking they're essential to their health.

- Pap smears every year until you're 30 - through the very years MOST likely to lead to unnecessary and possibly harmful treatment and when your risk of this cancer is lowest!
Finland, the Netherlands and several other countries don't test before 30 and the UK its age 25...

No other country (apart from Germany) tests women yearly.
Yearly smears send very high numbers of women for colposcopy/biopsies for false positives. (the DeMay article and many others)
Over-screening leads to over-treatment and that's a fact.

Bizarrely, from age 30, the interval drops to 2-3 years after the most damage has been done!
This seems to be counter to everything I've ever read on the subject.
Your risk of cervical cancer rises with age;
The harm to benefit ratio makes it unethical to test young women and women who've never been sexually active.
It seems like these recommendations are designed to harm as many women as possible.
Why would young women need more pap smears than other women?
The medical journals make clear this is a rare disease in young women and that pap smears are unreliable picking up the rare case in that age group anyway.

I really think the US recommendations need to be challenged and changed...
They guarantee many of your women will end up being harmed by this testing.
I would include in "harm" simply putting women through this examination...many women find it a negative experience. (discomfort, pain, embarrassment, humiliation, fear, anxiety etc)

There seems to be a real enthusiam in the States to put women through the most invasive of exams and tests for no good reason and/or far too often...or even when it is NOT recommended by the vast majority of the world's doctors for good reasons and to contain harm.

Other countries have problems as well...over-detection, overtreatment and issues with informed consent...but the US system is by far the worst in my opinion and really endangers the health of women.
Women obviously believe they should follow these guidelines to protect their health - when I would argue, the reverse is true - they are more likely to damage your health.
It's really frightening when a medical association can make recommendations that will have such serious repercussions for the majority and are unlikely to benefit many women at all.

It seems countries who don't consider the harm to the majority of women are wholly engaged in the pursuit of cancer, even the very rare cases and have no regard at all for the majority of women...women who don't have cancer.
Surely it should be a woman's choice whether she accepts that thinking.
Also, it seems fairly clear to me that these excessive and unnecessary measures DON'T pick up more cancer anyway, they just send more women for distressing follow-up.

I don't know if anyone else has realized how rare this discussion is...and on a forum set up and moderated by a doctor!
I tend not to post on many sites, but occasionally such irresponsible advice is given to women, it prompts me into action....my posts usually don't appear on the forum (even though I cite medical journals etc)
People just don't want to hear anything negative about testing - doctors have a conflict of interest (IMO) and many women are absolutely convinced they were saved by testing or that they're doing the right, responsible and mature thing.
I firmly believe when people have closed minds and discussion is taboo, the subject is never advanced...and in this case, that's dangerous.
I'm sure that's why these things continue in medicine because of the silencing of critics and the deliberate programs used to frighten and misinform women.
Thank you Dr for giving us a voice.

Janice O said...

My doctor follows those rules with one exception...the yearly smears continue after you reach 30.
The excessive rules are followed to the letter and the more liberal interval from 30 is completely disregarded.
If you don't agree, your birth control is stopped.
I no longer need birth control and have stopped being tested...definitely a response to being forced into over-examining and over-testing for so many years. I've also had LEEP procedure....which was a very bad experience. Given I was 24 at the time, I can only assume it was probably totally unnecessary.
I haven't decided whether I'll resume testing in the future.
Given almost all doctors demand all or nothing, it makes it difficult.
I'm not prepared to subject my body to these excesses anymore, enough damage has been done.
I think women should be allowed to protect themselves from yearly testing and the increased risk of biopsies. The pressure can be resisted if you don't need birth control. I do think the pressure applied makes women afraid to accept more relaxed testing schedules anyway....we've been frightened into believing yearly smears offer the best protection from cancer.
I just feel numb and absolutely "over" the whole business. I've reached a point were that feeling is greater than my fear of cancer.
No doctor has ever mentioned false positives and over-treatment to me.
The test is presented as perfect, with no side effects or risks and mandatory.

The motivation can't be to catch more cancer.
Looking at the various linked material, it just sends more women for colposcopy.
Less appears to be more with pap smears.
The more moderate countries seem to have lower rates of cancer and protect many more women from biopsies.
I can only think that the CHANCE of catching that rare cancer means more than harming lots of women.
I guess one missed cancer may mean one large law suit.
It may be the risk of a single law suit means these excessive recommendations give DOCTORS the best protection.
It seems to have nothing to do with our health.
Looking at other countries and researching the topic it nows seems well established that these recommendations are not in the best interests of the overwhelming majority of women. Not at all...
I wonder whether their attorneys drafted these recommendations.
They probably think that no one died from a biopsy, so no harm done really...
Whereas over-examining and over-treating lots and perhaps harming lots with the remote chance of catching extra cancer or rare cancers in teenagers justifies the harm done to the majority.
It seems unethical to me.
Isn't the medical motto, "do no harm" above all else?

Anonymous said...

I saw this piece in the BMJ by an American doctor who believes oral contraceptives should be available over the counter.
I doubt doctors will ever give up control over the BCP...power over the Pills means power over and control of women.
There is no way they would ever allow women free access to BCP's.
All of these exams and tests would then be a matter for us... yes or no and when...
That would never be acceptable to them.
I think the current situation is an abuse of power.
Many women would still have these exams and tests because they'd be afraid not to...but some women would choose not to have them.
I don't see what is so shocking about that...we all decide to do things every day that might affect our health and things a lot more serious than skipping smears and exams, like smoking, drinking alcohol, being overweight, having a bad diet and failing to exercise. These choices are part of being an adult.

The value of these things is a matter of opinion anyway when you consider the error rate of the test and the low risk of this cancer.

http://www.bmj.com/cgi/content/full/337/
dec23_2/a3044

Joel Sherman said...

Thanks for all the references, ladies. I've certainly learned from them. I stay neutral because it's not my field and I'm not competent to make any recommendations either for or against your positions. I wish another physician would post to defend the 'American' recommendations, but it's probably not going to happen.
But please keep posting information on the subject and your experiences. I'm here to discuss and learn.

Joel Sherman said...

I have copied this post here.

VNB has left a new comment on your post "Cancer Therapy & Privacy Angels Part 2":

Birth trauma certainly happens and there are various support groups around....my friend joined a support group run by a local psychologist...there were 26 women in the group.
I don't know whether its "common" though...
I've heard many women say, "you collect your dignity on the way out of the hospital", but that may be a reference to the exposure necessary to give birth and some of the undignified procedures.
There is a website for birth trauma victims in most countries...some of the birth experiences are very bad.
I can understand why these women end up feeling traumatized.
I know myself...doing nothing about someone invading your personal space and treating you badly can stay with you.
Most people have experienced something like that..from an unwelcome pat on the bottom to assaults.
If you take some action, any action, even putting the offending person in his place, publicly shaming him/her...it can really help you to move on.
A friend was assaulted on a very crowded train in Japan a few years ago. (she was an exchange student) At the top of her voice, she shouted for someone to push the emergency button because a man was sexually assaulting her. In that way she took control and stopped the assault.
None of us can say how we'd react in that situation....whether we'd be silent or make a scene.
vicki
http://birthtraumacanada.org/

Anonymous said...

Most American doctors test from around 16 or 18 and then annually until old age.
I read recently that a high % of 80-somethings in the States still have annual pap smears.
That means a HUGE number of smears over your lives.
Compare that to the chart that was linked...Finland has much lower rates of cancer than the States, yet their women only have around 7 tests in total.
An American woman might end up having 68 or 70 smears if she has them annually from age 16/18 until she's 85!!
You have MORE cancer and have 10 TIMES MORE smears than the country with the lowest rates of cancer.
Even if a US woman stops having smears at 70, she still has almost 8 times more smears than Finnish women.
How on earth can your doctors justify doing that to you?
You also face annual gyn exams that are not done overseas and you can't get the Pill unless you agree to having the lot every year.
This is one woman VERY pleased she's not American!
That information alone should be enough to start an investigation into US recommendations.

Anonymous said...

I certainly don't want to engage in what you referred to earlier as "gender wars," Dr. Sherman, but as I read everyone's comments, I can't help but wonder why men are not facing as close medical scrutiny as women are in regard to HPV and the troubles it may cause.

It's a two-way street and these potentially harmful HPV strains are carried and passed around by men too, so why no "required" annual testing of them? I don't see any of the fearmongering and scare tactics used with women patients being used with men.

Why no outcry from our physicians or blazing news headlines about the dangers of men contracting one of these harmful strains and/or passing it to their partners? I read one article recently that said the FDA has approved or will shortly approve the use of the HPV vaccine in young men/boys, but I've not seen anything beyond that article on the subject. So why aren't there more news stories and headlines in regard to men and HPV? Why aren't we seeing TV commercials in which young men are saying they want to be "one less?" Just doesn't make sense to me.

Elizabeth said...

HPV causes problems for men too...
I've read that HPV is connected with anal and penile cancer, both fairly rare cancers.
I know some gay men have anal smears.
The main worry for men would be genital warts.
However, men certainly carry HPV and can pass it on...(like women)
If you're a virgin and your sexual partner is not, he can give you HPV....
The really amazing thing...even if you ask him to get checked for STI's before you become intimate, there is currently no HPV test for men.
A Dr can see warts if they're present, but you can be a carrier and have no symptoms.
So a man can't even check whether he's a carrier (as I understand)
If he hasn't been sexually active, then you're fine and if he always used condoms, you have a reasonable chance.
I understand condoms aren't 100% though as men can carry the virus on skin that isn't covered by the condom.
Currently doctors say every woman who is sexually active is at risk of cervical cancer, but there are certainly degrees of risk.
When you look at the numbers, its a fairly small risk anyway...even for a high risk woman.
It's certainly not the threat we're led to believe...
I agree with you though...all the pressure seems to be on women.
I guess men may get pressured about other things...although I always thought it was only addressing half the problem vaccinating young girls and women against HPV. (the Gardasil vaccine)
I'm sure men could also benefit from protection from this virus and you'd have the added benefit of dealing with the entire problem.
I don't know much about Gardasil, but have read some doctors are concerned about the side effects of the vaccine and some US doctors have decided not to vaccinate any more of their patients.
I think it always pays to do your own research before agreeing to these things.

Joel Sherman said...

Thanks for the info Elizabeth. You stimulated me to look further.
Here is a very good summary from the CDC (Centers for Disease Control) re HPV. All of you interested in cervical cancer should look at it.
A few random points I learned. There are many kinds of HPVs and not all cause cancer. The viruses that cause genital warts do NOT cause cervical cancer.
I also wonder if girls who get the vaccine when young need any regular testing and pap smears. At the very least it should be less needed if the vaccine is worth anything. Don't think the vaccine has been around long enough for the answer to that question to be known.

Civil comments contrasting the differences between men and women’s treatments and problems are quite welcome. After all, much of this blog concerns gender issues. What I mean by ‘gender wars’ are hostile comments directed against the opposite gender. We all have problems that are valid and should be discussed.

Elizabeth said...

Thanks for the link Dr Sherman.
I've heard a couple of doctors calling for Australia's program to be modified because of the impact of the Gardasil vaccine.
Of course, there were furious responses from a few politicians and doctors.
It seems the over-screening will continue in that country. The program IS being reviewed over the next year or so, but who knows whether that will result in change.

Sadly, screening seems to be controlled by political, legal, financial and social factors rather than medical and scientific.
It would be helpful if a general test were devised so people could check their HPV status.
I understand the most dangerous strains of HPV are 16 and 18...
I read that genital warts were caused by HPV...on reviewing that reference you're quite right...they are caused by the low-risk HPV that is not linked to cancer.
The reference actually says that IF a man has genital warts, you should assume, to be on the safe side, that he also carries the high risk strains of HPV as well.
I assume this is to reinforce the need for regular screening.
I learn more about this subject every day.
I've found many doctors simply dismiss any evidence that goes against their screening practices and beliefs.
You may well know MORE about this topic than many specialists in the area. It seems to me many doctors stopped reading and listening many years ago.

http://www.mja.com.au/public/issues/
185_09_061106/wai10809_fm.html#0_CHDDDDGD

This article is by Gerard Wain, a senior Australian gynaecologist.
Dr Wain has caused a stir in the past by saying women under 25 were wasting their time being screened for cervical cancer.
He's also in favour of screening every 3 years, not 2 yearly...to reduce over-treatment.
I don't doubt some lives have been saved by this screening, but I also factor into any success the health of the majority of women.
I don't agree that saving a few lives justifies putting so many women through so much UNLESS they freely and with complete knowledge of the risks agree to do so...
That doesn't happen and has never happened, in my opinion.
Dr Wain wrote this article before the government funded Gardasil vaccine program took place.

The article shows the US has more cervical cancer, even though their women have MANY more smears than any other women around the world.

Anonymous said...

Some of you may care to look at a speech made in 2005 at the University of Sydney regarding informed consent and breast cancer screening.
I agree that informed consent is also a serious issue with cervical screening.
The over-treatment of healthy women to catch a relatively small number of women is a serious concern. Most women are unaware of the risks of testing.
The way these tests have been "marketed" to women falls well short of full and frank disclosure...and that is necessary for any woman to give her informed consent.
Is it ethical for a government and screening program to place public health goals ahead of the rights of individual women to make informed decisions to screen or not?
I don't think so....particularly when the risk of harm is now well known and would be of concern to many informed women.
PJ

http://www.ctc.usyd.edu.au/cochrane/
publications/presentations/Breast%20cancer%20forum%20slides/Mammography%2030%20years%20later.pdf

Hexanchus said...

Joel,

Good link. I was playing around the CDC site and came across the NCCD section - here's the url:
http://apps.nccd.cdc.gov/uscs/

And another interesting page from ACS:
http://www.cancer.org/downloads/stt/CFF2009_EstCD_3.pdf

Some interesting info I gleaned...
Predicted number of cancer deaths for 2009:

cervical- 4,070
uterine - 7,780
ovarian - 14,600
breast - 40,610
prostate - 27,630
Total - 94,690

Now, compare this with the 200,000 projected annual deaths directly due to medical errors and hospital acquired infections....

Anyone else see the disparity in focus and efforts here?

Joel Sherman said...

Thanks for those links.
I have no doubt that few patients, both men and women fully understand the risk/benefit ratio when undergoing screening tests. Clearly these facts need to be better explained.
One startling fact from the statistics is that cervical cancer kills about 11000 per year, but testicular cancer is close at 8400 per year. Yet women are pushed to get pap smears yearly, but one hears very little about testicular cancer screening. Some physicians even advise against regular self examination of the testicles for fear of scaring patients about an uncommon cancer. God only knows why these are treated so differently. There's no logic to it.
Hexanchus, I must point out though when you include 200000 deaths from medical errors and nosocomial infections, you are comparing apples to oranges. The vast majority of these patients are quite ill and elderly to begin with and many if not most would have died from other causes. It's not comparable to previously healthy patients, many of them young, who die from cancer.

Colleen said...

"One startling fact from the statistics is that cervical cancer kills about 11000 per year, but testicular cancer is close at 8400 per year. Yet women are pushed to get pap smears yearly, but one hears very little about testicular cancer screening. Some physicians even advise against regular self examination of the testicles for fear of scaring patients about an uncommon cancer. God only knows why these are treated so differently. There's no logic to it." Quote: Dr Sherman!

Thank you, Doctor Sherman...
I've been waiting for many, many years to hear a doctor say just that.

It makes no sense at all...it defies logic.
I've looked for the answer over many years.

I've read that feminists pushed cervical screening onto the agenda before it was properly assessed as a suitable mass screening tool.
Some doctors objected and warned against it at the time only to be labelled "anti-women".
It seems that feminism and political sensitivity both played a part.
I'm sure there were other factors as well...including the pot at the end of the rainbow...MONEY.
All of this testing and treatment is worth a fortune.
If it is indeed true that feminists pushed screening prematurely, I think they did all women a huge disservice.
I think it was a sad day for women.
We lost control of our bodies and lives on that day.
Our bodies were taken up and individual choice and protecting our health came a poor second to achieving public health objectives.
Maximinizing screening at any cost was the firm strategy.
Screening is a good thing for all women was the motto.

I know many women felt unsafe all of a sudden. It was at that time I switched to a female doctor.
I felt uncomfortable seeing the family doctor for a sore throat only to receive pressure to have a vaginal exam.
It seemed it was "open season" on our bodies...and the most intimate parts of our body.
If we complained, we were silly, immature and taking a very serious risk with our health.
My female doctor has given me a very hard time over the years.
I've read all I can read on this topic and I still can't see how this test was ever approved for all women on a routine basis.
"It's part of being a woman"...
Ahhh, NO IT'S NOT...not this woman anyway.
The mind games and heavy handed tactics just don't make sense when you look at the risk of getting this cancer.

The sensible thing would be putting the enormous sums spent on this screening into research and new treatment & drugs for women and men who actually have cancer and leave the rest of us alone.
Why put so many women through examinations, colposcopies and biopsies to cover the small risk of this cancer? Factor in a hopelessly unreliable test and you're looking at serious and likely risk for healthy women.
These exams and procedures are at the top end on the discomfort and exposure scale.
Many women are distressed by these procedures.
I've read lots of articles on psychological "damage" caused by biopsies.
This is a common procedure (although most of these women are healthy and don't have cancer) and leaves many women with mental issues about their bodies, sex life, self-esteem and their partner's fidelity and some will have physical and long-term health problems as well.
Yet it happens every day...and more...we even include women who are no or extremely low risk.
You hear ludicrous things...teenagers having cone biopsies, virgins being tested and treated, women without a cervix being tested...
I will never understand how all of this helps women nor do I understand how this is permitted to go on and so rarely even questioned...
The attitude is lofty arrogance...how dare you question this life-saving test? Why haven't you been brainwashed along with everyone else is what they should say...
I have never been tested...they can call, write, harass and insult me.
I cannot do what makes no sense to me....my self-preservation instincts come into play.

Hexanchus said...

Joel,

A minor correction - the number of projected deaths due to cervical cancer is 4070.....11,000 is the number of new cases diagnosed.


I'll agree that a significant percentage of the 100,000 projected annual deaths due to nosocomial infections involve compromised hosts where other co-morbidity factors exist, but I hardly think it is most. That some are elderly, or seriously ill and might have died anyway doesn't in any way justify or diminish the fact they were killed by a hospital acquired infection.

The 100,000 estimated deaths due to medical error are an entirely different thing, and there is absolutely no excuse for them. Any co-morbidity factors simply aren't relevant. I had first person experience with this as a healthy 18 year old and missed becoming a statistic by a hair's breadth.

Yes I was comparing apples to oranges, but the point I was making was I find it ironic that so much effort is directed at a disease that kills a comparatively few number of people, while significantly less attention is payed to an issue that kills far more people, yet has a significantly higher potential return in terms of the number of lives saved if it was addressed properly.

celia b said...

Screening directed at men is treated and viewed very differently as well.
Like Anne (previous poster) my husband was "offered" screening for prostate cancer recently.
The doctor produced a sheet of information to assist my husband with his "decision making"!
The doctor's conclusion..."this test is not terribly good, some men choose not to have it...it often gets it wrong and that can lead to more serious things that carry risk like biopsies."

Well, excuse me, but isn't that the case with cervical screening and cervical cancer is far less common than prostate cancer.
Risks to our health don't seem as important nor are we regarded as adult enough to make our own decisions.

I've never been given any information and doctors either assume you'll have the test or have it regularly, "When was your last smear?" or "I'll do the smear now"...or "you must have pap smears" like you must pay tax.

I've never been "asked" or "offered" or encouraged to make a "decision" about this test.
I always refuse and doctors are shocked like I must be deranged.
I think the powers that be were very cunning in putting together a plan to pressure women...one that robbed us of our rights.
Doctors always assume we'll have the test and then the pressure is directly on us to refuse or explain ourselves.
You find yourself babbling and pleading your case. I don't want them is not a good enough reason.
It usually works for them.

I once questioned the value of cervical acreening on a health forum having regard to the amount of over-treatment and the fact this cancer only affects a small number of women.
I was reported to the moderator who didn't think my comments were helpful to women and might put some women off screening which would be irresponsible. My post was deleted off the site.
My comments were as valid as the others in fact, my comments were backed by medical references whereas the wild statements that were printed with no problem at all would definitely mislead and frighten women...THAT seems to be fine though.
Many health forums praise the pap smear.
I think it is wrong to present all the pluses of screening and consistently fail to mention the minuses.
It seems that opinion makes me an outcast, rebel, ratbag or all three...
The attitude now is quite odd.
If someone gets cervical cancer (and I certainly don't know anyone and doubt that's because they were all saved by screening!) the first question is, "Didn't she have pap smears?"...
If yes, panic and confusion.
If No, stupid woman, she had it coming....
The over-treatment...."thank God I don't have cancer"...
Gratitude and relief rather than anger.
The deceit has been so complete we even thank doctors for harming us as we're given the all clear after yet another biopsy.
Most of my friends are up to No 2 by now...
They can't work out why I've been so lucky.
The strange thing...even though I have serious misgiving about this test, I'd never advise another woman. I'd feel guilty if she had biopsies for a false positive or got cancer.
I therefore think every woman has to make up her own mind, shame doctors don't feel the same way.

Anonymous said...

Please forgive my rambling, Dr. Sherman, but all of this discussion has me wondering about something. It seems most healthy women would not have much reason to visit the OBGYN if paps and pelvic exams were only offered to us with ALL of the facts and not forced upon us through the pressure, shaming or scare tactics that so many of us have experienced. Yes, if pregnant, women would be coming in for regular check-ups, but pregnancy only lasts 9 months and most women aren't going to get pregnant year after year.

Aside from the women who have true gynecological problems, those who visit for the occasional gynecological concern, those who are pregnant, and those dealing with fertility or menopause issues, it doesn't seem there'd be much business for the OBGYNs. From the looks of things, it seems annual paps and pelvic exams are their bread and butter, so to speak. I'm not trying to say that OBGYNs are all out there just to make a quick buck and that these exams aren't ever of value, but it just occurred to me that without the many HEALTHY women who are pressured into yearly exams, the OBGYNs and others involved in the testing process would lose a large chunk of their business. It seems individual health histories and personal risk are thrown out the window in favor of blanket coverage of all women, regardless of how little some may benefit from these tests.

Joel Sherman said...

Thanks Hexanchus. I of course meant to say incidence of cervical vs testicular cancer, not mortality. There is in fact a substantial difference between the mortality of cervical cancer vs testicular cancer, maybe because testicular cancer tends to be caught earlier. But my point is still valid. Young men are rarely prompted to self examine though most are self aware.

Don't know why screening is handled differently between men and women. Probably many reasons. Some are historical. Looking at risk benefit ratios is fairly new whereas pap smears are old. Then there is a huge political push for women's health and very little for men's health. Don't know how big a role self interest plays, but certainly many gynecologic practices would be severely hurt if annual pelvics and paps were no longer recommended.

Shortly I will have to start part 2 of this thread as posting stops after about 200 comments.

Anonymous said...

In Australia we don't see a gynaecologist unless we're pregnant, planning a pregnancy or we have a medical problem.
The yearly gyn exams are not done here...
Women see their GP if they want contraception or screening.
I did read once that if women could get their Pills at a chemist shop, doctors consults would drop by a significant figure...from memory I think it was about 40%-45%...
Our doctors do mention screening, often at unrelated consults.
It is true that our doctors are paid to achieve high screening targets.
I was shocked to read that and asked my doctor.
She's very honest and actually told me the name of the Act...the Medical Incentives legislation.
She does ask women who come in for Pills or gyn matters and older women who come in for cholesterol and blood pressure checks.
She does recommend the test following the recommendations from the GP's association.
She admitted to me the cancer is "one of the less common cancers" and that she was also concerned about the "numbers of women getting abnormal test results" and being referred to gynaecologists.
That is one of the areas were our gynaecologists would make money, all the referrals.
I think it was the frankest talk I've ever had with my doctor.
We even talked about reducing the risks of a abnormal result by widening the gap between smears.
I will not follow the Australian guidelines any longer, they are excessive.
I sent a letter to Monash University, to one of their academics in the Medical Faculty.
His references were helpful.
I may screen every 5 years until I'm 50...
I might not...
For the first time in my life I feel "informed" and in control of my health.
I always hated that test and can't tell you how happy I am not to be dealing with it as much or at all in the future.
My doctor also admitted there are individual risk factors.
My risk is low...
She said a uniform screening interval is arrived at having regard to reduction in death rates only and it is therefore not possible to include individual risk in that equation.
I suppose that also opens them up to liability.
You may call yourself low risk, when you're high risk.
That is why it is up to each woman to name her screening interval.
We've never been encouraged to do that...if this information were on a news program, more women would do just that I'm quite sure.

Lane said...

I'm really confused about all of this testing.
I thought this cancer was a big problem and was really shocked to see the actual numbers.
Why have we been made to think this cancer is everywhere?
What is going on...who benefits from misrepresenting the situation?
If you save one woman and put 1000's through very unpleasant (and more for some women...pain, bleeding, fear) testing and more, is that acceptable?
I would have thought the rights of the majority come into it?
The majority have a right to be facts and not to be misled and used.
I agree if the facts were laid out on a table and women were totally free to make their own decisions...most women probably wouldn't bother with the test.
When I think about the embarrassment and stress caused by this test and the large number of women who go through even more when the test comes back abnormal, I think its unforgiveable...almost evil to do that to women.
We should be free to live our lives without this testing.
I agree that the downside of this test and the rarity of this cancer means this testing should be no more than an option - an option given to women with the added warning of exactly where it can lead...
Doctors must know the whole story...when something is rare and the test is fairly poor, why would it be pushed so much?
Doctors are obsessed with this test.
It's presented as a vitally important life-saving test absolutely mandatory for all women.
If the only test you have is not very good, why bother with it?
Why wouldn't you just alert women to the symptoms of cervical cancer and put your energy into cancer research and new treatments.
It would also make sense to put some money into an education program on how to protect yourself from this cancer.

Don't they care about our quality of life?
If it were targeted at very high risk groups, it might make more sense.
I would like to blame all of this on paternalistic practices...but that doesn't add up when we now have so many female doctors and many in senior positions.
Have they all been brainwashed as well?
How do they justify all of this when the facts and figures tell another story.
Don't they ask questions when the test is sold to them in medical school?
Aren't we talking about very intelligent people who wouldn't just accept everything they're told?
I know chest x-rays for lung cancer have been dismissed as a screening test because radiation can be harmful, yet mammograms are recommended for women.
I've heard that mammograms use 7 times more radiation than x-rays.
Lung cancer is common and affects one in 50 people. I think breast cancer is one in 68.
There may be other factors to consider, I'm not a doctor...but I'm now very suspicious of all these "life-saving" tests.
It really seems the medical world is united in deceiving and hurting us.

Anonymous said...

Great discussion.
Unfortunate that you'll never hear any of this from your physician.
I had no idea of the very real and serious risks of mammograms until I did some research after my second lot of biopsies.
I found a lot of information that I believe should have been provided to me before I had my first mammogram.
Not only are we given no information, most doctors urge us to have regular mammograms giving us no clue as to the serious concerns about this test held by many senior people in medicine.
When exactly do they plan to tell us?
I think as others have said these tests should be optional and risk information must be provided well ahead of any testing.
I found the comments in this paper helpful.
There is no discussion on cervical screening, but many of the general comments at the end are relevant to all screening tests.
"The value of a screening test has to be in doubt if the number of lives saved is miniscule compared with the number of people who are harmed by overdiagnosis, by unnecessary treatments, [and] by treatments that could have been delayed with no ill effects."
Prof. Efron directly:
"The people who say `We're saving lives' [by screening] are undoubtedly right . . . But the question is, what's the cost? We could save even more lives if all men had their prostates removed at age 50 and if all women had their breasts removed at age 50."
Taken from,
http://www.ratical.org/radiation/CNR/XHP/
MPDaXrayST.html#Part1
"Making Personal Decisions
about X-ray Screening Tests,
Such as Mammography and CT of the Lung, Colon, Heart, or the Entire Body by
John W. Gofman, M.D., Ph.D., Professor Emeritus of Molecular &
Cell Biology, University of California at Berkeley.
Egan O'Connor, Executive Director and Editor, CNR.
May 2002

HT

Joel Sherman said...

I've looked at the above link from HT. I can't really evaluate it. I think the risk from low level radiation such as now used in mammography is unclear. That doesn't mean the risk should be ignored but may mean that low risk younger women don't necessarily need annual mammograms.
If I come across further studies that are pertinent I will post it, but I certainly don't recommend avoiding screening mammography without discussing it fully with your physician. Unlike cervical cancer, breast cancer does indeed kill many women every year.

Anonymous said...

Susanne here again, Dr. Sherman.

I agree with the last poster about the risk information not being given about such routine procedures as the mammogram. Being a non-doctor, I probably don't know what the heck I am talking about, but I've often wondered why so many of these tests are recommended for ALL women by a certain age and are recommended to be done on an annual basis. It doesn't seem there is any wiggle room as far as individual health history is concerned.

What concerns me is that dentists also require annual x-rays, yet we are made to cover up from the neck down with a protective lead apron because the radiation may harm us. Why is it that annual dental x-rays may be harmful to the rest of our bodies but the radiation from annual mammogram x-rays isn't? That has always confused me.

Also, the nurse practitioner at the family Dr. I visit suggested that I might want to start annual mammograms at age 35 because my grandmother had breast cancer. My grandmother was not diagnosed until age 79 and that was after she had been on almost nonstop hormone replacement therapy (a likely factor, according to her docs) for well over 30 years.

I sometimes feel this annual testing business is getting excessive to the point where we must live in fear all the time that something is wrong with us. I know I certainly have become much more of a worrywart because of all these testing recommendations. I don't think that's the way to live. Some healthcare professionals tout these exams as "preventive" medicine, but I think true prevention lies in helping patients develop good habits, stop bad ones, and live their lives in as healthy a way as possible. That is just my non-doctor two cents, though.

Susanne

HT (helen) said...

Dr, this is the only point I'm trying to make,

"The external pressure on women to have periodic mammograms has been intense. But considering the uncertainty that mammograms will deliver more personal benefit than harm, "Rational women can make the decision not to have a mammogram, and no one should castigate them for doing that," says Russell Harris, M.D., of the University of North Carolina Medical School and member of a National Cancer Institute advisory board (in Greider 2002, p.15). "

When there is serious and considerable research suggesting risk from a cancer screening test, it should be given to me, I should be given time to read it, ask questions and it should be my decision whether I have the test.
This doesn't happen at the moment.

This blog alone contains some links to the research and statements made by the Nordic Cochrane Research Team and other well respected institutions.
How can all of this evidence be put to one side and a blanket recommendation remain for all women to have screening mammograms from a certain age?

I've looked at the research here and elsewhere and have decided not to have more mammograms.
That should always have been my decision and if I had been given access to this information five years ago, I wouldn't have been through two lots of breast biopsies.
I worry about all the extra radiation I received during the work-up and the damage that may have been done to my breast tissue. (and the stress!)

If we don't get risk information, if doctors enthusiastically recommend with no warnings, we're unable to make our own assessment of the risks. We're unaware there may even be risks.
I feel the risks are just too high.
I didn't make this decision quickly, far from it.
I know breast cancer is fairly common and I'm slightly higher risk because I've never had children.
At the end of the day, if the test presents its own risks, some of us may choose to be "breast aware".
I think that is my and every woman's right.
I agree with your final sentence that breast cancer is common and cervical cancer is not.
My doctor talks about cervical cancer far more than anything else.
That make me wonder whether doctors really have open and balanced minds about these things.
Do they actually "see" these tests with an open and rational mind?
If they do, why concentrate on a cancer that doesn't occur very often rather than concern yourself with more common cancers and heart health? Things that will strike down many more women.
I agree with the earlier post, doctors don't seem in the slightest bit concerned about heart health.
This makes me nervous to follow my and other doctors recommendations about screening tests.
Is it possible we are better judges of these things?
Thank you for this informative and interesting blog that contains so much food for thought.

Joel Sherman said...

Helen, as given in links up above by Dr Baum and others, there is controversy about how much good breast screening does vs. how much harm it causes. I think every woman should be aware of the controversy and their own personal risk benefit ratio. As I've said for prostate cancer, I believe the main problem is not with the screening per se, but with the follow up. My wife recently had an abnormality on her mammogram of fairly low concern for cancer. We're not doing anything besides careful follow up.
But your article dealt with the risks of low level ionizing radiation used in these tests. I haven't seen any medical studies that conclude that it's a significant risk. That doesn't mean the possibility can't exist, but it's no reason to panic about the safety of repeated annual tests.
Radiation doses keep getting smaller and safer. When I was a kid, you could walk into a shoe store and stick your feet into the x-ray fluoroscopy machine they had to check how well the shoe fit. It was fun to watch your toe bones wiggle in your shoe. Some kids did it everyday on their way home from school. That's incredible by today's standards, but 60 years later I guess I survived that danger.

Joel Sherman said...

THIS THREAD IS NOW FULL. PLEASE CONTINUE POSTING ON PART 2.

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