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Dr. Carol Meynen, M.D., F.A.C.O.G

Practice Limited to Gynecology. Hours by Appointment
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333 Anjou Drive
Northbrook, IL 60062
847-446-4370

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My views on ...

How often should I have mamograms?
How often should I have a Pap smear and HPV screening test?
Are Bisphosphanates Safe?
Cervical Cancer (HPV) Vaccine
Other Vaccines - influenza, H1N1 flu, shingles, Pertussis, Pneumococcus
HPV Screening
Plan B (The "Morning-After" Pill)
New drug for female libido is now available. Is Addyi appropriate for me?

How often should I have a mammogram?

In the absence of detailed information, I recommend annual mamograms. However, every woman is different.

What is the lastest information on routine mammograms?

In October 2015, the American Cancer Society (ACS) published updated guidelines for routine mammograms in women of average risk for breast cancer. Based upon new evidence, and emphasizing the elimination of as many screening harms as possible, the new guidelines cover the age for initial screening use of mammography and the subsequent frequency of screening mammograms. The new guidelines have the stated goal of "supporting the interplay among values, preferences, informed decision making, and recommendations."

This guideline update attempts to reduce the incidence of patient anxiety that may result from overly conservative management of breast cancer risk. Each clinical examination or mammogram may show a minor indication of potentially cancerous tissue leading to patient anxiety and further fears of additional tests and invasive procedures. Attempting to eliminate "as many screening harms as possible" translates into reduced onset and reduced frequency of screening mammograms.

What constitutes "average risk" of breast cancer?

The guidelines speak most directly to women of "average risk" for breast cancer, which the ACS defines as:

  • No personal history of breast cancer
  • No confirmed or suspected genetic mutation known to increase risk of breast cancer (e.g., BRCA)
  • No history of radiotherapy to the chest at a young age
  • No significant family history of breast cancer
  • No prior diagnosis of benign proliferative breast disease
  • No significant mammographic breast density

What are the ACS recommendations?

The ACS recommendations fall into two categories: strong recommendations and qualified recommendations. A strong recommendation is one that the ACS advocates most women of average risk should follow. A qualified recommendation is one that ACS believes should be discussed between the patient and her doctor to arrive at a plan in keeping with the patient's values and preferences.

  • Strong recommendations (favored for women of average risk)
    • Regular screening mammography should start at age 45 years
    • Screening should be biennial (every other year) at age 55 and thereafter
  • Qualified recommendations (acceptable options as agreed between the patient and her doctor)
    • Women who desire to initiate annual screening between the ages of 40 and 44 years should be accommodated
    • Between the ages of 45 and 54, screening should be annual
    • Screening may continue annually after age 55
    • Screening mammography should continue as long as the woman is in good health and has a life expectancy of at least 10 years
    • Clinical breast examination by a doctor is not recommended at any age

Has there been any professional reaction to the ACS recommendations?

Shortly after publication of the new ACS guidelines, the American College of Obstetricians and Gynecologists (ACOG) issued a formal statement in response:

ACOG maintains its current advice that women starting at age 40 continue mammography screening every year and recommends a clinical breast exam. ACOG recommendations differ from the American Cancer Society's because of different interpretations of data and the weight assigned to the harms versus the benefits.

ACOG strongly supports shared decision making between doctor and patient, and in the case of screening for breast cancer, it is essential.

Are there areas of agreement between the ACS and other professional groups?

There are 7 areas of agreement between ACOG and ACS recommendations, using both strong and qualified recommendations:

  • Screening from age 40 to 69 years is associated with a reduction in breast cancer deaths.
  • Annual screening for women in their 40s [although the ACS' 'strong' recommendation is that regular screening begin at age 45 instead of 40].
  • Screening for women 70 and older who are in good health (10-year life expectancy).
  • Annual screening yields a larger mortality reduction than biennial screening.
  • These recommendations still leave the "over-diagnosis/overtreatment" issue uncertain.
  • Insurance should cover screening at all ages and intervals (not just USPSTF 'A' or 'B' recommendations).
  • The patient should be involved in informed decision making.

What do these recommendations mean for the "average" woman?

Women may have an "elevated" risk of breast cancer related to many conditions not usually considered. In addition to genetic predisposition (race/ethnicity, family history), breast density may contribute-it may increase risk, and it certainly makes a mammogram harder to interpret. Hormone replacement, delayed childbearing (first child born after age 30) or lack of sufficient breast feeding (cumulative under 12 months), early menarche/late menopause all are factors that tend to increase breast cancer risk. There may be other environmental risk factors that contribute as well.

The recommendations emphasize that the patient should be educated and involved in formulating the screening plan. Ultimately, while the science and the doctor can help identify the relevant risk factors for a particular women, the plan will rest upon how much risk that individual can tolerate. Let us also not forget that the overall incidence of breast cancer is 11% in all women - perhaps not a low risk in itself.

I am concerned that the simultaneous ACS recommendations to stop self-breast exams, stop clinical breast exams and reduce the frequency of mammography may result in an unacceptably high incidence of relatively advanced breast cancer. While treatments are now more sophisticated than they were even 10 years ago, the majority of breast cancers are discovered at a relatively early stage and thus are eminently treatable. Delaying diagnosis cannot be helpful.

What I will be recommending to an "average" woman

I will continue to abide by the ACOG guidelines and suggest that women with an average risk profile begin annual screening mammograms at age 40. I also believe that self-exams and clinical exams have their place. However, each woman is unique and I want to discuss the alternatives with you.

If you would like to talk about your personal need for an annual mammogram, I am happy to discuss it with you at your next appointment. My role is to help you decide what is best for you.

November 2015

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New drug for female libido is now available. Is Addyi appropriate for me?

Many women over the age of 45 notice a significant decrease in their sex drive. Recently the FDA has approved the first drug, Addyi (filibanserin), to address that issue. Are you wondering if you are a candidate for this medication? Consider the following points:

  1. Addyi has only been approved for premenopausal women. That does not mean postmenopausal women cannot use it, but the FDA believes that the risks outweigh the benefits in that age group.
  2. The medication must be taken daily to be effective. Unlike Viagra, and the other ED medications, you don't take it just when you want the effect, you have to take it every day.
  3. The side effects include hypotension and fainting. This might not be a problem if you were taking it for its immediate effect and planning to stay in bed, but if you're taking it all the time it could be a serious problem - such as operating a car or heaving machinery. At this time, any long-term effects are unknown.
  4. Cost of treatment has yet to be determined. It is anticipated to be about the same as a month's ED treatment, or about $400 per month. This is unlikely to be covered by Medicare, since it's not approved for postmenopausal women.
  5. Results of study trials reveal very small improvements. The studies showed that whereas the beneficial effects of placebo were close to 100% over baseline (e.g. a doubling of sexual encounters in the course of a month), the additional improvement with Addyi was only about 20% (e.g. 120% of baseline). While this is statistically significant, it only translates to 0.7 additional sexual encounters per month.
August 2015

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How often should I have a Pap smear and HPV screening test?

Once again, guidelines for cervical cancer screening have been refined. As our understanding of HPV (human papilloma virus) disease has grown and our techniques for establishing an accurate diagnosis have improved, we have become more capable of discerning the appropriate level of management.

Prior to the introduction of pap screening in the 1950's cervical cancer was the scourge of women under the age of 50. It remains so in the developing world where women generally go unscreened. The goal of screening is to identify changes in the cervix before they become cancerous and to isolate and remove the abnormality, leaving a healthy cervix. Pap screening resulted in a 75% reduction in deaths from cervical cancer but initially at the expense of treating a lot of women with unnecessary invasive procedures such as hysterectomy.

The recent change in guidelines has to do with the technologies that have come about in the past 10 years or so-liquid based Pap smears and screening tests for HPV. I am sure that as the current cohort of young women is fully immunized against HPV with Gardasil or Cervarix, the screening recommendations will be further refined as they age.

In the past 30 years it has become evident that virtually all cervical cancer is due to HPV, and more specifically, certain strains of the virus that we are now able to screen for. Abnormalities that occur in Pap smears that are not due to these strains will almost certainly never result in cancer, but not all abnormalities that are due to these strains will progress to cancer either. Screening for HPV enables us to focus our attention on those women who are at high risk.

Exposure to these certain strains of HPV appears to occur only with sexual activity. There are other strains that cause hand and foot warts but will not cause cervical cancer. We are able to identify these high-risk strains on a liquid Pap smear with HPV screen. Most women will be exposed to HPV when they become sexually active but their immune system will suppress it within a few years. It is women whose immune systems don't suppress HPV who are at risk. It may also be that HPV can recur at a later time, like shingles recurs from the chicken pox virus. We know little about this as yet.

Frequency of tests for teens

About 70% of women are exposed to HPV during their lifetime, based on previous studies of large populations. About 25% of young women (under the age of 30) will test positive at any one time. Therefore we don't recommend HPV testing of young women as a general rule. New, current guidelines recommend beginning screening at age 21. This is a change from the prior guidelines which recommended initiating screening 3 years after beginning sexual activity. I am more comfortable with the prior guideline since I have experience of a 19 year old woman with a pre-cancerous condition 3 years after becoming sexually active. I have also seen 20 and 21 year-old women with cervical cancer. For this reason, if I see a young woman who has been sexually active, then I will recommend Pap screening. If I see a 21 year-old woman who I am convinced is not sexually active, I have no problem delaying initiating Pap screening (but not delaying examination!)

Testing for ages 21 to 30

Between the ages of 21 and 30 the new, current guidelines recommend a Pap test every three years. However, because a liquid based Pap test is at best 80% accurate, and recognizing that women at these ages are likely to be the least responsible about their health (due to lack of money or high mobility), I still recommend an annual Pap smear without the HPV co-testing. If two years go by without screening, I will order an HPV test, too, since it is a more accurate way to determine risk for an abnormality. (Most women with HPV will not have cervical dysplasia-they are just at higher risk and more careful screening is required.)

Testing for ages 30 to 65

Between the ages of 30 and 65 the new, current recommendation is to have a Pap test plus an HPV co-test every three-to-five years. I am perfectly comfortable with that. If a woman catches HPV the day after I have received normal Pap and negative HPV screen test results for her, then the probability that she will develop cervical cancer before I repeat her Pap test in three years is very remote. It does make remembering when the Pap needs to be repeated more difficult for both patient and physician.

Frequency of tests for women over 65

After age 65, the recommendations get fuzzy again. Several organizations recommend that we cease screening at 65-and that may be appropriate if a woman has negative Pap and HPV tests and she doesn't acquire (or her partner doesn't acquire) a new partner. Now that women commonly live to be over 90, I am uncomfortable letting a sexually active woman who will live for another 25 years go unscreened. Cervical cancer is as aggressive as ovarian cancer, so I would recommend screening with Pap and HPV co-tests every three years for any woman over 65 who is sexually active and every five years for one who isn't.

Testing for women after hysterectomy

Regardless of age, a woman who has had a hysterectomy in which the cervix was removed no longer needs a either a Pap smear or HPV test, unless the surgery was done for cervical dysplasia or uterine cancer.

To summarize, my screening recommendations are:

  1. Initiate Pap screening within 3 years after sexual initiation.
  2. Until age 30 screen annually with Pap alone. If more than two years elapse without Pap screening, then add HPV co-test.
  3. Between 30-65 screen every three years with a Pap and HPV co-test.
  4. Screen sexually active women over age 65 with a Pap and HPV co-test every three years. Screen other women over 65 every five years.
  5. Cease screening after hysterectomy.

An annual gynelogic exam remains important

Remember that a gynecologic exam is not just about Pap screening. General health screening, breast exam and preventive counseling are also important aspects of the gynecologic visit. Most internists have neither the time nor the expertise to deal with these women's issues. An annual gynecologic exam is an investment in good health and quality of life for years to come.

May 2013

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Are Bisphosphanates Safe?

Local and national news have been carried a story about a report given recently at the National Association of Orthopedic Surgeons concerning a particular type of femoral fracture that is not prevented by bisphosphonates, and claiming that bisphosphanates cause a "brittle bone" condition after a period of time. Of course, the truth is probably more complicated. Recently, there has been a series of published rebuttals from the New England Journal of Medicine and the American College of Rheumatologists which I interpret as follows.

Bisphosphonates seem to prevent one of the two types of hip fractures - the intertrochanteric fracture - but not the other - the femoral fracture. These fractures are of approximately equal frequency in untreated women but the femoral fractures appear more frequently in women treated with bisphosphonates.

I believe this is fundamentally a statistical anomaly. Because bisphosphantates prevent the intertrochanteric fractures, the femoral fractures appear to be more common in a cohort of treated women. Both types of fracture are considered to be "osteoporotic" fractures; however, the majority of hip fractures do not occur in women with "osteoporosis", the majority occur in women with "osteopenia". This is because there are many more women with osteopenia and even though their risk of fracture is lower than that of women with osteoporosis, the occurrence is greater.

For example, if you have 10,000 women with osteopenia, which carries a 1% fracture risk, that group will incur the same number of fractures (100) as a group of 1,000 women with osteoporosis, which carries ten times that risk - because 10% of 1000 is also 100. If bisphosphanate treatment reduces the intertrochanteric fracture risk 50% but not the femoral fracture risk, the 10,000 treated women will have 75 fractures (50 femoral, 25 intertrochanteric) and 10,000 untreated women will have 100 fractures (50 of each). However, the treated women will then appear to have twice the risk of a femoral fracture (50) versus the intertrochanteric fracture (25), as compared to untreated women (50 of each). Thus, while the treated women have a smaller risk for any fracture (75 versus 100), their risk for femoral fracture seems to rise.

With this understanding, does it make sense to continue bisphosphanate treatment indefinitely? We don't know. Since bisphosphanates are stored in bone for as long as ten years, there may be a time when women can stop taking them and still be protected. This has not yet been demonstrated in studies, but many physicians are recommending that patients take a "drug holiday" for several years while studies are conducted. The course of treatment could also depend upon on the degree of risk for the patient or her degree of bone loss. That is not known either. We do know that our means of measuring risk and treatment results are imperfect and we can only estimate an individual's results on a statistical basis.

References:

April 2010

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Cervical Cancer (HPV) Vaccine

Many people are asking about the new cervical cancer vaccine. Recently released by Merck, it involves a six-month course of three vaccinations at 0, 2 and 6 months. Each vaccination costs $130 for the vaccine alone, so the total cost of treatment will exceed $400. Researchers estimate the vaccine to be about 70% protective against cervical cancer in addition to protecting against vulvar warts and potentially against vulvar cancer as well. These are relatively short-term studies — the trial group has only been vaccinated since 2002 so researchers do not know yet how long the vaccine will last or if there will be any side-effects.

Cervical cancer results exclusively from exposure to the HPV virus from a sexual partner. Condoms are about 80% protective. Most young women are exposed to HPV without being aware of it, and their immune systems are able to clear the virus within a few years. This is the reason gynecologists recommend that young women wait for three years after becoming sexually active before starting Pap smears — there were many abnormal Pap smear readings which were treated when they would have resolved spontaneously. It is unlikely that a cervical cancer will develop in less than ten years except in a person with a compromised immune system (someone with HIV or a kidney transplant); therefore, waiting three years to begin Pap smear screening is thought to be safe. Eating a healthy diet, limiting sexual partners, using condoms, avoiding stress, and particularly avoiding smoking cigarettes are all ways to reduce risk. Once screening begins, it should continue annually with a Pap smear. Alternatively, an HPV test could be administered every three years (see below).

Even if the new HPV vaccine is used, Pap smears must continue because they detect about eight other HPV viruses that can cause cervical cancer. The vaccine should be effective against vulvar warts or condyloma, but these are relatively easy to treat if caught early and have no long term health consequences. Cervical cancer is extremely rare in women who receive annual Pap smears (I haven't seen a case in over 10 years) and vulvar cancer is rarer still. It is exciting to think that these diseases are preventable with a vaccine; however, given their rarity — about 1 case in every 10,000 women — and the cost of $400, we would expect that 10,000 women would spend $4,000,000 to prevent just one case. If we could predict who would be at risk (i.e., promiscuous, not using condoms, no health care), then those would be the women who should be vaccinated before they become sexually active.

That being said, I am in favor of vaccination for young women between the ages of 12-25, ideally before they become sexually active. Even if they have been sexually active the vaccine is recommended since the number of women who have been exposed to all four of the HPV strains the vaccine targets would be very small. In an ideal world, both boys and girls - all humans - would be vaccinated and HPV would be eliminated like smallpox has been. Until that happens, at least we can minimize the damage to young women, physiologically, psychologically, and economically, by vaccinating them against HPV and preventing them from getting several STDs that can cause significant havoc in their reproductive tracts.

September 2009

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Other vaccines

  • Influenza - About 30 million people seek care for seasonal influenza every year, most of them either the very old or the very young. Over 90% of influenza related deaths are people over 65 years of age. The seasonal flu vaccine reduces infection 70-90% in those under 65 and 50% in those over 65, but it also reduces hospitalization and death by over 50% in those over 65. For this reason, the CDC recommends annual vaccination for all persons over age 50 in addition to people who are immune compromised or have chronic diseases, international travelers, caregivers and providers of essential community services.

  • H1N1 - The 2009 "Swine flu" or "Novel Influenza" vaccine is due in mid October 2009. So far, this virus seems to particularly afflict younger people who have not perhaps been exposed to similar influenzas in the past. For this reason, the early doses are recommended for people between the ages 6 months and 24 years or those who care for them, healthcare personnel, and those over 24 with chronic disease or compromised immune system.

  • Shingles vaccine - Shingles will afflict one third of adults who were exposed to chicken pox as children. Severity increses with age and 50% of adults will have shingles by age 65. Recurrence occurs in 15%. The vaccine reduces both the incidence and the severity of shingles and is recommended for all adults over age 60 whether or not they have had a prior episode of shingles.

  • Pertussis - Whooping cough is primarily a disease of infants and children but is highly communicable. The pertussis vaccine administered in childhood does not prevent disease in adults and they remain a huge reservoir of disease to afflict infants and children. A single pertussis booster is recommended for adults when they receive there next tetanus booster.

  • Pneumococcus - There are over 500,000 cases of pneumococcal disease reported in the US each year. with a fatality rate of over 5%, up to 60% in older adults with pneumococcal pneumonia. Vaccination reduces the incidence of invasive disease 65-85% and is recommended for all people over age 65 and for those under 65 with chronic disease or immune compromise, including asthma and cigarette smokers.
September 2009

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HPV Screening

Many women are seeing advertisements or commercials for a combined HPV screening test and Pap test as a more accurate way of predicting cervical cancer. The HPV test has been available and used for several years as a "reflex" test after an abnormal Pap smear to determine if there is anything serious. Used proactively along with the liquid-based Pap tests, the HPV screening test can ascertain if there is any current HPV infection that will lead to an abnormality within the next few years.

Most insurance companies will now pay for a combined Pap smear plus HPV test once every 3 years (since it costs three times as much as a regular Pap smear). Women still need to visit their physician each year for a gynecologic exam (breast exam, ovarian functions, etc.). If the patient were to contract HPV in the meantime, it is unlikely to progress to cancer in someone whose immune system is intact. This does not preclude an ANNUAL exam, at which time women should be checked for breast and ovarian disease and vulvar health and other health issues may be addressed. Please see my views on the frequency of Pap & HPV tests.

There were over 11,000 cases of invasive cervical cancer in the USA in 2008. This is a completely preventable disease. The combination of HPV vaccination and HPV testing should allow us to eliminate this scourge.

July 2006

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Plan B (The "Morning-After" Pill)

Now that the FDA has finally approved Plan B for over the counter use, the wise consumer needs to know how and when to use it safely. Plan B is a safe drug - there were never concerns about its safety. It is a strong progestin that a woman takes twice, twelve hours apart, which makes the endometrium inhospitable for implantation. It is 95% effective and has essentially no side effects. It should be used within 72 hours of unprotected intercourse - the earlier, the better. If the woman is already pregnant, the short duration of use will not harm the embryo in any way. It will not abort an ongoing pregnancy. It is the same drug which has been used safely in birth control pills for over thirty years. The only limitation to its usage is its cost - if you were going to use it more than once a month, you might as well take birth control pills.

So how do you know if you need Plan B? Fertilization of the egg can occur with sperm that has been in the reproductive tract as long as ten days, so the only time a woman is "safe" from pregnancy is after ovulation has occurred - from about ten days before her next menstrual cycle through the first day or two of menstruation. A woman with a particularly long cycle (32 days or longer) might get away without protection for the first week after her menses, but this is like playing Russian Roulette. Breakage or slippage of a condom would warrant Plan B from about the third day after bleeding starts through about ten days before the next menstruation is due. You can now obtain Plan B at any pharmacy without a prescription if you are over 18 years of age. It is certainly safe for those younger than 18, but it must be administered under supervision of a professional.

August 2006

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©2013, Carol A. Meynen, M.D. All rights reserved.