Will women fall through the cracks?
The new Pap testing guidelines are easier to accept because we are learning more about HPV, the causative agent of cervical cancer. Nevertheless, I worry that many women will fall through the cracks as we extend the Pap testing interval to 2 and 3 years and that we will become static in the battle against this almost completely preventable cancer. And because the ObGyn is the only physician many women of reproductive age see with any regularity, screening for diabetes, hypertension, and other chronic conditions often falls to us. These conditions may all go undetected if the woman does not come to see us for a Pap test. Cancer of the cervix may not kill her, but a stroke or myocardial infarction certainly can!
Guidelines are just that—guidance. I am mindful of the new recommendations, but I tailor my advice to the risk profile of the individual and remain cognizant of the prevalence of diseases in the population I serve.
Dr. Joshi reports no financial relationships relevant to this article.
CHALLENGE 3: Responding to atypical glandular cells
Larry C. Kilgore, MD
Dr. Kilgore is Gynecologic Oncologist at the University of Tennessee Medical Center in Knoxville, Tenn. He serves on the OBG Management Board of Editors.
From my vantage point as a gynecologic oncologist, one of the most pressing issues facing gynecologists and primary care providers who screen patients for cervical cancer is ensuring proper management of women whose Pap smears reveal the presence of atypical glandular cells (AGC). In more than 30% of cases involving AGC, a serious condition is present. Although squamous cancer precursors are the most common finding, other possibilities include:
- adenocarcinoma in situ or adenocarcinoma of the cervix
- hyperplasia or adenocarcinoma of the endometrium
- adnexal malignancy, including ovarian and tubal carcinoma.
The general application of liquid-based Pap testing has not led to proper identification or adequate protection of women against glandular malignancy of the reproductive tract. At a time when the proportion and absolute number of patients who have glandular malignancy of the cervix are on the rise, the clinician is challenged to appreciate the gravity of these findings and follow management guidelines closely.
Regrettably, many practitioners do not adhere to the latest guidelines on AGC, last updated in 2006. According to these guidelines, the clinician is obligated to:
- perform colposcopy on each patient who has a test result classified as AGC
- obtain an endocervical curettage, regardless of the patient’s age
- test for HPV at the time of evaluation
- obtain an endometrial biopsy in women who are older than 35 years or who have unexplained uterine bleeding.
It is not appropriate to repeat the Pap test or otherwise delay thorough evaluation.
In addition to proper management, the gynecologist should educate other primary care health professionals who perform cervical cancer screening about the importance of following AGC guidelines. Proper respect for this important clinical issue is imperative.
Dr. Kilgore reports no financial relationships relevant to this article.
CHALLENGE 4: Meeting the specialty’s research needs
Anita L. Nelson, MD
Dr. Nelson is Professor of Obstetrics and Gynecology at Harbor–UCLA Medical Center in Torrance, Calif. She serves on the OBG Management Virtual Board of Editors.
Research in women’s health has grown tremendously since the late 1980s, when the Government Accountability Office (GAO) issued several reports revealing that women were being deliberately excluded from clinical trials. Despite a greater emphasis on women’s health since then, research is sorely needed in many areas.
Consider unwanted pregnancy as a disease that, every year, kills and mutilates millions of women worldwide and orphans untold numbers of children. We need new, inexpensive, reliable, convenient methods of birth control that are rapidly reversible and that do not require extensive training to implement. One option might be an intracervical contraceptive device. In addition, choices in injectable contraception should be expanded, and studies are needed to understand (and control) unscheduled spotting and bleeding.
Research is also necessary to find better ways to motivate couples to control fertility, and to plan and prepare for pregnancy. For women who have infertility, we need better, less expensive techniques that can be shared with low-resource regions.
Other areas ripe for research:
- Obstetrics. Given that preterm labor is one of the greatest challenges in the United States, it is amazing to realize that we do not yet understand what factors control the onset of labor. In addition, extended research on the pathophysiology of preeclampsia and eclampsia is needed to develop effective treatments and reduce the serious complications caused by these processes.
- Oncology. Ongoing efforts to identify new markers to detect gynecologic cancers at a very early stage need to be amplified. Simple interventions to prevent those cancers in high-risk women should also be studied. For example, obese postmenopausal women have a high risk of endometrial cancer; clinical trials of prophylactic progestin therapies are vital.
- Application of the Human Genome Project. The information that we glean about individual risk should be translated into targeted approaches to promote health and to tailor therapies to the individual patient.