Three of the most misunderstood health screenings for women

Family physician Jonathan Vinson, M.D., clears up a few things about:
One screening that you may not need as often as you thought

If you're still getting a Pap test every year, you're probably overdoing it. None of the authorities on this cervical cancer screening recommends annual tests anymore. In fact, the three leading authorities – the American College of Obstetrics and Gynecology, or ACOG; the U.S. Preventive Services Task Force, or USPSTF; and the American Cancer Society, or ACS – all recommend against testing every year for women whose prior tests have been normal. Their reasoning is that annual testing may do more harm than good, increasing the likelihood of false positives and unnecessary interventions, and costing women more in terms of time, money and anxiety. (Note: don't confuse the specific Pap test with the more general pelvic exam, during which your doctor checks the health of all of your pelvic organs – that important exam has its own set of guidelines.)

Annual testing was important years ago, when the Pap smear was less sensitive – the theory being that doing an imperfect test more frequently would increase the chances of finding signs of cancer in the cervix. But today's Pap tests are much more sensitive, so we can test less frequently with greater confidence. Also, vaccination against HPV may, with time, lessen the overall disease burden of cervical cancer.

This is what the three leading authorities now recommend:

Begin Pap testing at 21: In the past, Pap testing was recommended earlier, but experience has shown that although most teenagers do get exposed to HPV – the sexually transmitted virus that causes cervical cancer – their immune systems often eliminate it.

From 21 to 30, get a Pap every two to three years: Women in their 20s are the most likely to develop changes in the cervix that can lead to cancer. Perhaps that's because they are still dating and being exposed to more partners and more strains of HPV. The more conservative ACOG recommends testing every two years for women in their 20s, while the USPSTF and ACS say that once every three years is sufficient. Each woman should discuss this with her doctor and make a decision based on her lifestyle, sexual activity and personal preferences.

From 30 to 65, get a Pap every three to five years: After 30, women tend to be in more stable relationships, which means that they are exposed to fewer new strains of HPV and have a much lower risk of developing cervical cancer. At this point, the ACOG, USPSTF and ACS all agree that women can space their Pap tests three years apart, as long as their recent prior test results have been normal. The USPSTF and ACS extend that to every five years if the test includes both a Pap and a high-risk HPV test.

When testing is no longer needed: After age 65, women statistically have such a low risk of cervical cancer that Pap tests are generally considered unnecessary; however, as with all recommendations, the final decision is up to a woman and her doctor. In addition, women who have had a total hysterectomy – including removal of the cervix – no longer need to be tested for cervical cancer.


One screening that you may – understandably – be confused about

Mammography guidelines can be very confusing, especially for women in their 40s. Before age 40, most organizations agree, mammograms are not very useful, because younger women tend to have dense breast tissue that is difficult for mammograms to visualize. After 50, most everybody agrees that women should have regular mammograms to detect breast cancer in its earliest, most treatable stages. But for women in their 40s, the recommendations vary.

The ACS and ACOG recommend annual mammograms for all women beginning at 40. The USPSTF, on the other hand, says that unless a woman is at high risk for breast cancer, there is little value in starting mammograms at all until age 50. Each organization bases its guidelines on scientific data, but their interpretations and perspectives are different. For example, according to the ACOG, while it's true that the rates of breast cancer for women in their late 30s and 40s are lower, their cancers tend to be faster growing and more aggressive, which is why they should start screening at age 40. However, argues the USPSTF, this would apply a broad guideline to an entire population in order to screen for something that affects a relatively small number of people. Looking at the statistics population-wide, the USPSTF asserts, there is not enough evidence to support screening all women in their 40s.

Most everybody agrees that once women reach 50, regular mammograms are beneficial, and should be continued until age 75, as long as a woman remains relatively healthy. However, the organizations still differ on how frequently women should be screened: the ACS and ACOG say every year, and the USPSTF recommends every two years.

Either choice is reasonable. Talk it over with your physician in light of your family history and other risk factors. If you have family members who developed breast cancer in their 40s, 50s or 60s, then you might lean toward earlier and more frequent mammograms – especially if you smoke or take long-term hormone replacement therapy. If you have no risk factors and no breast cancer in your family, then leaning the other way is a perfectly valid choice.


One important screening that you may be overlooking

Most people worry about cancer and heart attacks, but they aren't particularly afraid of osteoporosis. Meanwhile, osteoporosis and its complications take a huge toll on people's lives. Nationwide, the number of fractures caused by osteoporosis each year exceeds the number of strokes, heart attacks and new breast cancer cases combined. The mortality rate for women one year after a hip fracture is 17 percent. It's even higher for men, but women develop osteoporosis at twice the rate of men. It's a much bigger problem – on both a population basis and an individual basis – than most people realize.

With bone density screening, we can find people who are heading down this path and start working with them to prevent further bone loss. The screening is as simple as an X-ray, and the guidelines are pretty straightforward: the USPSTF recommends screening women at age 65 – or sooner if they have multiple risk factors. Those factors include a family history of osteoporosis, smoking, being underweight, drinking too much alcohol, long-term steroid use, past fractures, and Caucasian race. (The frequency of follow-up screenings depends on the results of your first screening.) So if you're 65 or have multiple risk factors, it's time to talk to your doctor about this.

Confused by the guidelines? Let your doctor be your guide.

Trying to keep all the guidelines straight, when even the authorities don't agree on every point, can be enough to set your head spinning. And the fact that published guidelines exist doesn't mean that every woman on the planet ought to adhere to them rigorously – there may be reasons to vary from the guidelines based on your individual health and lifestyle. That's why it's so important to have a good relationship with your health care provider – we're here to help guide you through these decisions, taking into account both the science and your individual circumstances. The next time you're in your doctor's office, have a conversation about how best to apply the guidelines to your own life.

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Jonathan Vinson, M.D. answers some questions regarding bone density testing in this video.
Is there a women's health issue you'd like to understand better? Our online Women's Health Library provides clear information on many health issues, medical tests and medications related to women's health.

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Jonathan Vinson, M.D., practices family medicine and obstetrics at Providence Medical Group-The Plaza. He enjoys building long-term relationships with families at every stage of life. "I especially enjoy obstetrics," he says, "because pregnancy, birth and child-rearing are such intense and transformative episodes in our lives." Watch Dr. Vinson's video bio. To make an appointment, call 503-215-6405.